Principles and Practice of Burn Care

Post Burn Sequelae and their Management
487
in burn conferences as to the superiority of skin flaps and
split skin grafts over one another for post burn neck
contracture management. As has been said above, there is
no absolute indication for skin flap application as the bed is
excellently graftable. The reasons given for use of flap cover
are: (1) It does not require postoperative splintage as it does
not contract, (2) it is one stage, (3) it has better color/
texture and hence better esthetic result, (4) long term follow
up is not required.
After going through the published literature and the
photographs therein (without doubt the best results of the
author(s) of those articles), the following facts become
obvious to the present author (The author has intentionally
omitted the references). (1) The main aim of the operation
was excision of the post burn scar in the neck (which had
a mild element of contracture) rather than a severe
mentosternal contracture; (2) Even when the contracture
was very severe, no importance was given to the scars on
the surrounding areas of lower face, chin, shoulders and
upper chest; (3) The healthy normal skin of the flap stood
out conspicuously from the surrounding scarred skin like
an island in the ocean. This appearance of the patient can
be compared to that of a poor beggar wearing a highly
expensive neck-tie! Consequently, the patient as a whole
does not have a pleasing appearance; (4) The donor site
morbidity of the flap itself was never taken into
consideration; (5) Any flap, even a relatively thin one, tends
to conceal the details of the neck contours and gives the
neck a 'milk can' appearance. When free flaps are used, the
circular suture line contracts and gives the flap a 'biscuit' or
'cookie' appearance obscuring the underlying contours
further. When local pedicle flaps are used, they may become
very thick even after many years when the patient gains
weight spoiling the initial good result; (6) The flaps may be
hairy depending on the donor site as well as the 'hairiness'
of the individual patient. While presence of hair is obviously
undesirable in females, it is no good either even in males
because of totally different appearance from the normal
male in shaven as well as non-shaven state; (7) All flap
operations, including free microvascular flaps, were only
theoretically single-staged. Actually they required 2-4
thinning procedures in addition, to get the desired contours,
over a period of time requiring frequent patient visits. Some
flaps were raised after tissue expansion. (8) Most of the
articles are case reports of a few patients; (9) Secondary
graft contraction in split skin grafts and the need for
splintage, pressure garments, massage etc. have been
presented as something highly unmanageable. This is not
true; (10) In the unfortunate event of a pedicled flap failing
partially, use of a split skin graft to close the resultant wound
leads to a very poor esthetic result. Failure of a free flap
will necessitate the use of large sheets of skin grafts which
may not be now available.
The present author has exclusively and extensively used
skin grafts for management of post burn mentosternal
contractures over the last 23 years in a center with a great
workload of post-burn sequelae and special interest in
treating them and has achieved excellent results. He has the
following reasons for using split thickness skin grafts for
diffuse neck contractures (Figs 34.14A to D and 34.18A to
34.21D). (1) As a rule, it is a single-staged procedure, rarely
requiring a second stage to improve the result; (2) The graft
fits better into the surrounding post burn scars and grafted
raw areas without any sudden changes in color and texture
etc. (3) There is minimal donor site morbidity; (4) Far less
operating time is required; (5) Excellent contours with finer
details can be achieved; (6) It is suitable for mild as well as
the most severe cases (7) Microsurgical skills and operating
microscope are not required; (8) In the unfortunate event
of a partial graft loss, minor graft losses heal by conservative
management whereas bigger areas, even if grafted again,
do not spoil the esthetics of the final result; (9) Most patients
have multiple contractures, scars, losses and other
reconstructive needs out of which neck is the first major
one to be addressed (next only to upper eyelid). Improvement
after neck release tremendously improves the appearance
of the patient and his/her confidence in the treating surgeon.
Hence, there is no question of poor compliance or lengthy
follow up; (10) The contractures from as a result of full
thickness burns which were not treated by split skin grafting
in acute initial stage. After release of contracture neck, a
split skin graft only is required; (11) Last but not the least,
a split skin graft only can take care of the more than one
billion populations. Thus, while more and more articles with
newly discovered/modified old flaps will continue to appear
in journals, the massive load of burn victims will continue
to be benefitted only by the simple skin graft. It must be
made amply clear to the reader that the author is not "anti-
flap" and has no objection to treat the patient shown in
Figures 34.22A and B using an appropriate flap as the scar-
contracture was limited, surrounding region normal and
overall other reconstructive needs nil.
The sheets of skin grafts are applied with their junction
lines horizontally placed and immobilized using tie-over
sutures. Postoperatively, after the graft is taken up, the patient

488
Principles and Practice of Burn Care
Figs 34.18A to C: (A and B) A 7-year-old boy with severe contracture of neck, right axilla and both elbows along with ectropion of lower
lip with microstomia and extrinsic ectropion of lower eyelids. (C) A timely sequential release of all contractures
Figs 34.18D to F: Follow up at 18 years of age
A
B
C
D
E
F
Figs 34.19A and B: 50-year-old female with severe mentosternal contracture with completely everted lower lip. (B) Result after 1 year
with adequate lip seal (Pre and Postoperative view)
A
B

Post Burn Sequelae and their Management
489
Figs 34.19C to F: Front and lateral view of post burn contracture
neck in a 23-year-old female. Note the deformed lower teeth. (E and F)
Postoperative result with complete restoration of cervicomental angle
and lip seal after 1 year
Figs 34.20A and B: 25-year-old female with severe contracture of
neck, right axilla, right elbow and breasts
is given simple neck collars and chin-neck pressure garments
and other care as detailed above for grafts. Patient's
compliance in postoperative care of the graft is surgeon
dependent. Better the surgeon in his doctor-patient
relationship, better is the result!
Contractures of the Axilla
Contractures of the axilla are also very common. Similar to
neck, the skin is thin and loose and the patient tends to keep
the arm adducted. A contracture of the axilla may involve
only the anterior or posterior axillary folds or there may be
a diffuse contracture involving the whole of axilla
(Figs 34.17A to 34.18F and 34.20A to D). Sometimes, the
anterior and posterior folds are extensively involved but the
normal hairy skin area in the apex of the axilla is spared. In
the latter case, while releasing the contracture, the incision
has to be made in such a way that neither the normal skin
of the apex of the axilla is divided nor its anatomical position
altered. Once the contracture is released, thick split skin
graft is applied with tie-over sutures and the arm splinted
with an aeroplane splint with arm abducted at an angle of
110 degrees. This splint is continued till the graft is mature
and there is no risk of graft contraction. In selected cases,
scapular or para scapular flap, if available and sufficient,
can be planned preoperatively to provide cover and may
obviate the need of postoperative splints which are
cumbersome. Sometimes, patients present with axillary
contractures which are linear webs and a single or multiple
Z-plasty or other multiple inter-digitating flaps-plasty (e.g.
V-M plasty) may be designed and contracture treated.
C
D
E
F
A
B
C
D
Figs 34.20C and D: 2 years after release and split skin grafting. Note
the improvement in breast contours without any surgical intervention
on breast

490
Principles and Practice of Burn Care
Figs 34.22A and B: Hypertrophic scar lateral neck with mild
contracture. Pre and early postoperative result (See text)
Figs 34.21A and B: Severe mentosternal contracture with ectropion
lower lip and pulled up breasts. After release and split skin grafting,
full range of movement achieved. Good contours of the neck
Figs 34.21C and D: 9-year-old girl with severe cervicomental
contracture and depigmented scars on anterior trunk. Postoperative
result after 8 years. Release of contracture and split skin grafting
done
Flexion Contractures of the Elbow (Cubital
Fossa), Wrist and Knee (Popliteal Fossa)
Flexion contractures of the elbow (cubital fossa), wrist and
knee (popliteal fossa) are similar in many respects. A severe
contracture developed in any of these sites in early childhood
and coming for corrective surgery after many years in
adulthood is very difficult to correct completely because
the shortened musculo-tendinous units and neurovascular
structures stand out as bow-strings and any further attempt
to straighten them forcefully may injure and damage them.
Moreover, the joint may be subluxated or deformed so as
not to allow the limb to straighten despite complete release
(Figs 34.8A to D and 34.12A to E). In these cases, after
maximal possible release, the raw area is splinted with a
Crammer wire splint which is gradually straightened over a
period of 10-14 days and then split skin grafted. Here again,
the release incision is given opposite the point of maximum
tension, usually opposite the joint line. Since rigid post
operative splintage (to counter secondary graft contraction)
is easier in a straight limb, an intermediate thickness skin
graft can suffice for excellent results (Figs 34.18A to F). In
bilateral elbow contractures, both sides should not be
operated together to allow the patient some self reliance.
However, bilateral knee contractures should be operated
simultaneously to make the patient ambulatory as soon as
possible.
A
B
C
D
A
B

Post Burn Sequelae and their Management
491
Contractures of groin, when unilateral, may cause
difficulty in normal standing/walking. When they are bilateral,
the contracting band usually goes from one thigh across
groin and pubis to the other groin and thigh leading to
difficulty in abduction of thighs (perineal contractures)
(Figs 34.23A to C).
The breast is discussed in detail later in this chapter
while contractures and deformities of hand are devoted an
entire chapter elsewhere in this book.
POST BURN LOSSES
Burn victims may be left with losses of one or more
specialized structures or body parts which may be either
extremely difficult to reconstruct or else may not be possible
to restore. Thus, there may be loss of scalp, pinna,
eyebrows, nose, moustaches, nipple-areola complex, penis
and testis etc. Amputations of digits or limbs at various
levels, especially after electrical burns and loss of testis, are
almost beyond the realm of reconstruction. They need
prosthetic restoration. Loss of thumb may be treated by
reconstruction with one of the many available techniques.
Loss of vision is very common after chemical burn injuries
to eye.
These losses are also dependent on the depth of burn.
However, they may sometimes be prevented, e.g. by timely
escharotomy in full thickness circumferential burns of limbs
or digits or by prevention of chondritis (with eventual loss
of pinna) by appropriate management of burns of pinna in
the acute stage.
Scalp
Deep dermal thermal burns of the scalp often heal with
alopecia patches due to damage to hair follicles and scarring.
On the other hand, electrical burns of the scalp often involve
full thickness of the scalp and even the calvarium. These
wounds do not heal without appropriate surgical intervention.
The initial intervention may leave the patient with patch of
split skin graft over the calvarium. These patients later
present for restoration of hair bearing scalp. A number of
patients reach a plastic surgeon after long periods of 6 months
to 2 years or more following electrical burns of scalp. They
have a chronically exposed calvarium.33 Typically, these
patients had no access to specialized treatment of burns
and were treated by dressings alone. Their wounds heal by
formation of multiple contractures. However, since
contraction is limited on rigid skull, they are ultimately left
with an area of exposed calvarium with dried up outer table
of skull or sequestrum formation (Figs 34.24A to F). The
patients with chronically exposed calvarium should be treated
by removing (chiseling out) the sequestrum of the outer
table of skull and wound closure by application of a split
skin graft over the diploe. Only very small wounds can be
closed primarily using local rotation flaps in the same stage.
Figs 34.23A and B: Bilateral groin contracture
Fig. 34.23C: After release and split skin grafting
A
B

492
Principles and Practice of Burn Care
Figs 34.24D to F: (D) Chronically exposed calvarium (12 months post burn). (E) Sequestrum removed exposing underlying
granulation tissue. (F) 3-weeks later, healed with split skin graft
Figs 34.24A to C: (A) Chronically exposed calvarium (15 months post burn). (B) Sequestrum removed exposing underlying
granulation tissue. (C) 4-weeks later, healed with split skin graft
Transposition flaps are absolutely contraindicated in these
situations as they leave the alopecic areas in the form of
split skin graft over donor site and greatly jeopardize the
adjacent areas which may be needed later for tissue
expansion for ideal scalp restoration.
The restoration of hair bearing scalp has been
revolutionized over the last 25 years with the introduction
and availability of tissue expansion and expanders
respectively (Figs 34.25A to 34.26E). In earlier times, the
aim was only to restore the anterior hair line using one of
repeatedly delayed strips of available hairy scalp. Presently,
the surgeon tries to excise all of non-hair bearing areas.
Except for very small alopecic areas which can be excised
and primarily closed either by simple undermining and
advancement or by local rotation flaps after triangulating
the defect, all other larger areas are treated by tissue
expansion.
It is the author's practice to get scalp completely shaved
at the time of insertion as well as at the removal of expander.
The former has shown many unexpected scars in the scalp
which have changed the plan of tissue expander placement.
This also allows proper part preparation which is so very
essential when one is inserting a foreign body. It is also
possible that the ideal size and shape of the expander is not
available (very common in a developing country). In such
circumstances, use of a less than ideal expander may give
excellent results if the entire scalp is shaved and the expander
has been inflated a little more than the calculated amount.
At the time of removal one may have to change the plan of
movement of the expanded tissue because the expansion
did not proceed in the desired direction. It proves handy if
the whole scalp is shaved and prepared. The tissue expander
is inserted in subgaleal plane. The incision should be in the
healthy skin, 1.5-2 cm away from the scar/graft with
A
B
C
D
E
F

Post Burn Sequelae and their Management
493
healthy skin junction, to avoid breaking down of the incision
at the time of expansion. The port should be as far away as
possible to avoid overlapping with the expanding implant
and getting punctured unintentionally.
The incision is closed in two layers with deeper layer of
polyglactin910 and skin with prolene. A small amount of
sterile normal saline is injected at the time of insertion to
flatten out the folds in the expander.
After a period of two weeks, once the wound has healed,
gradual inflations are started. The inflations are done
biweekly till the required scalp has been generated, usually
a period of 3 months. The amount injected in any one sitting
should neither blanch the overlying skin nor should cause
undue discomfort to the patient. A record must be made of
the dates and the amount injected. One must also observe
for any thinning of the suture line or the skin being expanded.
The expansion may be stopped for a while till recovery
occurs and then, proceed slowly and cautiously. Strict
asepsis and anti-septic precautions must be taken at all times
to avoid the complication. After complete expansion has
been achieved, the expander is removed through the old
incision and expanded skin moved over the alopecic area.
Eyebrows34,35
Facial burns are very common and so are the burns of
eyebrows leading to loss of hair bearing supraorbital region.
The loss of eyebrows may be unilateral or bilateral. Also it
may be complete, i.e. no hair is left or it may be incomplete,
i.e. a significant number of hairs may still remain. Without
eyebrows the face looks bland. However, the eyebrow
reconstruction is usually the last operative intervention on
the patient. This is because their restoration is purely
aesthetic in nature and they are to be restored only after the
scars and contractures of the surrounding facial region have
Figs 34. 25A to E: (A and B) Front and lateral view of post burn cicatricial alopecia in 20-year old girl with severely recessed anterior hairline.
(C) Tissue expansion in progress (over 15 weeks). (D) Complete coverage of scalp with expanded tissues. (E) Patient trying to show complete
restoration of normal anterior hairline
A
B
C
D
A
Figs 34. 25A to E: (A and B) Front and lateral view of post burn cicatricial alopecia in 20-year old girl with severely recessed anterior hairline.
(C) Tissue expansion in progress (over 15 weeks). (D) Complete coverage of scalp with expanded tissues. (E) Patient trying to show complete
restoration of normal anterior hairline
E

494
Principles and Practice of Burn Care
Fig. 34.26A: Post burn alopecia in 23-year-old girl
Fig. 34.26B: Tissue expansion in progress
Figs 34.26C to E: Final result with complete restoration of scalp hair
settled well so that the reconstructed eyebrows do not
change their position. Thus, one can rightly term the
eyebrows restoration as providing a 'finishing touch' to face.
In the intervening period, the patient is advised to use an
eyebrow pencil. Many patients, especially females, may opt
for continued use of pencil rather than go ahead with
reconstructive surgery. In this non-operative option the
patient has to take the trouble of reconstructing the eyebrow
daily. In the surgically reconstructed eyebrow as well, the
patient has to take the trouble of regularly trimming the hair
as they grow. This gives a waxing and waning of the
eyebrow density and bushiness as compared to the
uniformity of eyebrow pencil use. The male patients,
however, should always be offered surgical reconstruction.
A number of operative techniques are available to restore
the eyebrow when a normal healthy skin is available in the
region. In post burn cases, however, the brow region is
generally scarred or split skin grafted and a pedicled flap
from the scalp is ideal. It must be added here that excisional
surgery is absolutely forbidden in this region in acute stage,
even if the burn appears full thickness as the eyebrow hairs
have very deep seated roots and may survive the injury
giving reasonable result.
An island pedicle flap from the scalp based on the
ipsilateral superficial temporal artery (posterior branch) is
marked. The position of artery is found by light palpation
and confirmed by Doppler, if available. Planning in reverse
is done to mark the skin island on the scalp. The flap can be
raised in two ways. The skin island is raised on an almost
skeletonised superficial temporal artery and vein, and then
transferred to the supraorbital region with the pedicle being
tunneled through the intervening skin from the pre-auricular
region to the recipient site. This method always has a danger
of partial or complete loss due to island being not supplied
or drained adequately or compression of the pedicle in the
tunnel. A safer, although two-staged, technique followed
by the author is to take a broad pedicle artery and vein and
intervening fascia with the skin island being 1.5 to 2 times
C
D
E

Post Burn Sequelae and their Management
495
the width of desired eyebrow and transferred over intact
skin with interpolation. This is an excellent and safe
technique for the novice or the surgeon who performs this
operation only occasionally. Since the initial inset is hundred
percent, the pedicle is divided without any delay at the end
of 3 weeks. Once the tissues have settled completely after
a period of several months, the desired eyebrow width and
shape are marked at appropriate place on the hairy island
and excess excised. The newly created eyebrows require
frequent trimming for esthetic appearance (Figs 34.27A to
34.28B).
In patients where the eyebrow loss is partial or else the
supraorbital skin is reasonably healthy and the surgeon has
a feeling that hair grafting may be successful, it may be
attempted. One may do the older techniques of strip grafting
(not preferred due to high failure) or the newer techniques
of micro-follicular or single hair grafting as one does for
male pattern baldness of the scalp.
Nose
The nose occupies the most prominent position on the face
making it vulnerable to almost every burn injury involving
the upper part of the body and there may be associated
inhalational injury as well. A partial thickness burn injury
can lead to scarring of the skin of the nose with essentially
preserved shape. It may lead to narrowing or eversion of
Fig. 34.27A: Patient with hypopigmented scars
on left face , ectropion of left upper and lower
eyelids and left half of upper lip with loss of
ipsilateral eyebrow
Fig. 34.27B: Appearance after release of ectropion
of both lids and lip and excision of scar and cover
with a single sheet of graft from thigh in one stage.
At 8 days
Fig. 34.27C: At 6 months
Fig. 34.27D: Eyebrow reconstruction being done by pedicled
superficial temporal artery flap
Fig. 34.27E: Final result—2 years follow up. Well settled graft and
symmetrical eyebrows

496
Principles and Practice of Burn Care
external naris (nasal stenosis or ectropion respectively). A
full thickness burn of skin or a still deeper injury may lead
to a subtotal loss of nose, requiring lining, support and cover
for its reconstruction. Total loss of nose, i.e. loss of bony
framework is extremely uncommon. The restoration of
nasal structure, function and cosmesis is vital to restore the
self esteem of the burn victim. Here again, whole of the
plastic surgeon's armamentarium for reconstructive
rhinoplasty in various permutations and combinations along
with his ingenuity is needed to achieve the goal of 'return to
society'. In most of the patients who come for
reconstructive rhinoplasty to a plastic surgeon, the cause is
either a human bite or other trauma or else they have a
post-excisional (malignant tumors) defect. The
reconstructive options of using forehead flap or nasolabial
flaps which give excellent results in these patients are
generally not available in burn patients. Commonly, the less
than ideal options of restoring the nose from medial arm or
other distant regions have to be chosen.
In patients with scarred nasal skin cover only, the latter
can be replaced as a whole with a sheet graft or expanded
thin skin from the forehead, if available. The aim should be
a result that mixes well with the surrounding face which
has healed spontaneously or after application of skin grafts
or flaps, etc. Before this excision of scar is done it is
preferable that the surrounding scars/grafts/flaps have well
settled and will not cause any extrinsic pull on the nose.
Thus, ectropion of the eyelids and upper lip, microstomia,
tight skin of the cheeks, bands passing from nose to cheeks,
etc. should have been corrected. The scar should be excised
thinly preserving whatever subcutaneous tissues to prevent
a 'skeletonised' look to the nose. When cover is being
provided with a graft, the incision at nasofacial junction
must be slightly on to cheek as well as with a slight bulge
towards the face to take care of secondary graft contraction.
One must try to feed excess of graft as well. These measures
prevent the junction line between nose and face to come
over the nose and spoil the outcome. The graft can be
harvested from the medial arm or groin (Figs 34.4A to D
and 34.31A to C).
The management of nostril stenosis is difficult and every
effort should be made in the acute stage for its prevention
or minimization by using moulded splints till scar maturation.
Once the scars have matured, the stenosis should be
corrected by excision-release of scar and use of inter-
digitating or local flaps and thick skin grafts. The ectropion
of the external naris, again, needs release and cover either
with thick skin graft or local flaps, may be from the nasolabial
region, if available. Whenever grafts are used at free margin
of the nose, postoperative moulds must be worn by the
patient till graft maturation.
The patients with subtotal loss of nose require recreation
of the defect and assessment of the available donor site(s)
for provision of lining, cover and support. For smaller
defects, local flaps from nose or nasolabial region, if
available, can be used. For larger defects forehead skin, if
healthy and sufficient, can be used for cover with lining
being provided by turn down flaps. They do not need a
support as the forehead tissues are sufficiently tough to
maintain their shape. Forehead flap rhinoplasty using one
of its various modifications like midline or oblique forehead
Fig. 34.28A: Eyebrow being reconstructed by pedicled flap from
scalp. Note the width of flap
Fig. 34.28B: Result after trimming of flap and hair

Post Burn Sequelae and their Management
497
flap or after tissue expansion is commonly done procedure
performed by every plastic surgeon for non burn indications.
Detailed techniques are available in all modern plastic surgical
books.36
Very commonly, however, a patient with post burn loss
of nose does not have the forehead tissues fit for use and it
is in these patients that the medial arm tube has to be
constructed and transferred in stages for reconstructive
rhinoplasty. In cases where this is also not possible, other
donor sites like groin or abdomen have to be considered for
constructing the tube. To avoid multi-staged operations and
their attendant morbidity, microvascular free tissue transfer
has been done by various workers using flaps based on
radial or dorsalis pedis artery, etc.
The detailed technique of arm tube rhinoplasty is not
covered in modern plastic surgical books as it is considered
old-fashioned and outdated (Figs 34.29A to 34.30D). Also
it does not give as good results as forehead flap. The author
has, however, found this donor site to be an excellent source
in those burnt patients where forehead is scarred or grafted.
Although multi-staged in itself, one must remember that
construction of tube may not add any stage as it is usually
combined along with some other reconstructive need of
the burnt patient. The only real morbidity is for a period of
three weeks when the first inset is done on the nose and the
arm has to be fixed to head. The delay and division of the
tube flap from the arm, inset on the nose and return of
pedicle to arm can all be done under local anesthesia. The
skin of the medial side of the arm is chosen as it is fair-
colored, non-hairy, easily covered by elbow level sleeves
and is mostly in contact with chest wall and hence not
visible.
Two parallel incisions, about 8 cm. apart and 16 cm
long, are made in the long axis of the arm and deepened till
Fig. 34.29A: Young adult female with post burn extensive facial
scarring, subtotal loss of nose and complete loss of vision both eyes
due to homicidal acid burns
Fig. 34.29B: Result after resurfacing of forehead, release of upper
lip ectropion and arm tube construction
Fig. 34.29E: Successful return to
society
Fig. 34.29C: Arm tube inset on to nose
Fig. 34.29D: Final result after nasal
reconstruction

498
Principles and Practice of Burn Care
the whole of subcutaneous tissues. Undermining is done in
this plane and a bipedicled, random pattern skin flap (2:1
ratio) is raised. The longitudinal cut margins of the flap are
stitched to each other forming a sort of suit-case handle. It
is not possible to stitch the ends of the tube and triangular
raw areas on the under surface of the ends of skin tube and
the donor bed are split skin grafted with a single sheet graft
using tie-over sutures. Once the wounds have healed and
the graft taken up, the tube is allowed to 'mature' and become
soft and supple over a period of 10-12 weeks. The proximal
end of this tube is, then, delayed by a transverse incision
and the first inset on to nose is done in 7-10 days. The
lining is provided by turn over flaps from the defect margin
and/or from the nasolabial flaps. The tube is opened at the
seam for the required length and the first inset is done to
form the ala, the columella and the lower part of the nose
(as much as possible) as described by Sawhney (1981).37
The width of the adult male nose is around 7.5 cm at the
broadest part; hence the width of tube was kept at 8 cm to
allow for tissue loss in scarred seam. At the end of 3 weeks,
the tube is divided at appropriate level keeping the tissues
required on the nose. Final inset is done on the nose and
pedicle is returned back after excising the skin graft on the
donor site equal to the length of pedicle available for return.
Moustaches38-42
When a patient presents with a severe ectropion of the upper
lip, a release and thick split thickness skin graft application
may restore the normal appearance in a child or an adult
female. However, in adult males, (Figs 34.31A to C) absence
of the moustaches may be resented and one may request
for its restoration to have a more natural and masculine
appearance.
Hair-bearing skin to upper lip can be transferred from
the scalp or from the neck. Very few papers with case
reports only have been published in literature about
moustache restoration in male burn patients. A bi-pedicled
flap from either of these sites can be transferred as a 'visor'
flap('bucket handle').The neck flap needs appropriate delays
as they are not axial pattern and do not contain any named
vessel in their pedicles. However, a scalp flap may be raised
on both superficial temporal vascular pedicles and needs no
delay. An L-shaped pedicled flap based on a single superficial
temporal artery incorporating the parietal and occipital scalp
with primary closure of the donor site has been described
to restore whole of the moustache. A free flap based on one
superficial temporal artery or an occipital artery has also
been described to restore the moustache with anastomosis
being done with facial vessels.
Pinna
Reconstruction of pinna or auricle in patients of microtia is
a challenging task for a plastic surgeon with a select few
doing the job and producing reasonably good results. One
can imagine the challenge when healthy skin cover of
microtia is replaced by scarred skin in a burn patient. The
results are bound to be far from satisfying the patient and
the surgeon alike. The pinna is burnt as a part of extensive
burn injuries involving face and upper parts of the body.
The skin of the pinna is very thin with almost no
subcutaneous tissue especially on its anterolateral aspect.
The underlying cartilage is directly dependent on overlying
skin for its nutrition. The pinna may be lost directly due to
a very deep burn injury or else following chondritis of
auricular cartilage leading to its resorption and deformation
of the three-dimensional architecture.
Figs 34.30A to D: (A) 20-year-old female with bilateral ectropion of eyelids and upper lip, subtotal loss of nose and complete loss of both
eyebrows. (B) After release of upper lip and eyelids. (C) Arm tube inset on nose. Note the small and scarred forehead. (D) Nasal reconstruction
completed
A
B
C
D

Post Burn Sequelae and their Management
499
The post burn deformities of the pinna may range from
minor helical margin irregularities, loss of ear lobule,
auriculocephalic adhesions to complete loss of pinna. In
patients with loss of helical rim, skin tubes can be constructed
in pre or post auricular region or even in the neck and
transferred in stages. Loss of ear lobule can be dealt with
one of the various techniques like Zenteno Alanis, etc.
Adhesions between pinna and scalp need simple release and
application of thick split skin graft.
The reconstruction of total loss of pinna43,44 involves
framework fabrication from autogenous costal cartilage or
use of one of the various commercially available implants
(Silastic, Medpore ® etc.) and provision of skin cover. It is
the poor quality with respect to texture and elasticity and
shortage of skin that makes the draping of costal cartilage
framework or auricular implants extremely risky with ever
present danger of their exposure and a catastrophe.
Undermining of the scarred skin is dangerous in itself. With
the availability of temporoparietal fascial flap, the problem
of coverage has been solved to some extent. In case the
skin is reasonably healthy and can withstand tissue
expansion, the procedure can be done to regenerate sufficient
skin in case of its shortage. Ear reconstruction is necessitated
not only for esthetic reasons but also to support the
spectacles. In India, wearing ornaments in the pinna is
almost a rule in females of all age groups.
When pinna is reconstructed using an autogenous costal
cartilage, the synchondrotic portion of the sixth, seventh
and eighth ribs is harvested using extra-perichondrial
dissection to obtain a complete graft. Cartilage framework
fabrication is done with the help of a template and helical
and conchal margins are augmented. If local cover is
available, a thin pocket is created or else after an incision at
the appropriate place, the framework or an implant is covered
with temporoparietal fascial flap which, in turn, is split skin
grafted.
Breast
Burns of the anterior chest region are very common in female
children as well as adults. They are generally part of the
extensive burns of the surrounding areas i.e., head and neck,
abdomen, arms and axillae. In a prepubertal female child
the mammary gland which is 4-8 mm. in size is located
deep in the subcutaneous tissues. The bud is connected to
the nipple by the mammary ducts which are lined by
epithelium. Even in burns involving full thickness of skin,
the breast bud gets spared and the proliferating epithelium
Fig. 34.31A: 23-year male with post acid burns hypertrophic scars on
face and nose, ectropion of upper lip and loss of right eyebrow
Figs 34.31B and C: Release and split skin graft to cover the upper lip.
Nose has been resurfaced with a skin graft as an esthetic unit.
Eyebrow has been reconstructed from scalp flap (front and right
lateral views)
B
C

500
Principles and Practice of Burn Care
of the milk ducts regenerates a nipple like structure over
the developing mound. There may be lack of areola in such
cases and the nipple may be hypoplastic and of the same
color as of the surrounding skin. It is to be noted that
complete lack of development of breast i.e., mound as well
as nipple and areola complex (NAC) occurs only when the
NAC region has been removed energetically but
unfortunately during excisional surgery or else burnt deep
up to the muscles in a prepubertal child as is possible in
contact electrical burns (Fig. 34.32). Sloughing of NAC in
a conservatively managed prepubertal female child does not
mean that the mound will not develop at the time of puberty.
Hence, any form of surgical excision or debridement is
absolutely contraindicated in this region. These areas must
be allowed to heal conservatively with repeated dressings
and the raw areas should be split skin grafted after the
granulation tissue forms over the region. After complete
healing of the wounds, the grafted and spontaneously healed
areas are taken care of as usual with massage, pressure
garments etc. Surgical intervention of any sort is to be started
only after the onset of puberty when the breast development
begins.
Reconstruction of the Burned Breast45-47
Reconstruction of the burnt female breast is challenging
because it affects the emotional well-being of a growing
adolescent girl. Burns of the anterior chest wall in females
can result in a variety of deformities which are dependent
not only on the depth and extent of the burn but also on the
age of the female victim at the time of burn. In patients
who get burnt after the full development of the breasts,
there can be deformed breast(s) with or without partial or
complete loss of NAC. In prepubertal children, on the other
hand, the problem may not even be identifiable fully and/or
treatable till the child shows some signs of breast
development at the time of menarche. In adult females, the
presence of loose breast skin heals many raw areas with
contraction without any need of skin grafting leading to
"mastopexy" and sometimes better contours. This situation,
if unilateral, may call for improving the unburnt side by
appropriate operation to achieve symmetry of contours in
consultation with the patient rather than "surgically
deteriorating" the burnt side by releasing and inserting more
graft. Also, in children, more stages are required as
compared to adults due to continued growth of the breast
mound resulting in graft falling short in amount again and
again.
Reconstruction of the Mound
The reconstruction of the breast mound in post burn cases
differs greatly from that in post mastectomy cases. Whereas
in the latter case, the breast has been totally removed, in
post burn cases the apparent projection of the mound has
been suppressed by the tight scar over the breast tissue.
Thus, the bulk of breast mound is only apparently absent.
It is actually present beneath the tight scar (Figs 34.33A to
34.36E). It is only in an extremely rare case that the breast
was completely burnt right up to the costal muscles or when
it was unfortunately excised completely by the surgeon
during acute management that reconstruction of the mound
is required. In these cases the techniques used for
postmastectomy reconstruction like use of myocutaneous
flaps, free or pedicled, tissue expanders and silicone breast
implants etc. may be used. The author has no personal
experience of this requirement in his 23 years of experience
of working in the second largest burn center in the second
most populous country.
In patients who have post burn contractures of the neck
or axilla in addition, the breast reconstruction should begin
only after the former are released and their grafts/flaps well
settled. This is especially true in patients who have their
contracting bands of breast, neck and axilla in continuity.
The breast mound and its position improve considerably
after the neck and axilla return to normal.
Fig. 34.32: Contact electrical burns of right anterior chest wall up to
rib cage in a10-year-old girl with gangrene of right upper limb
necessitating below elbow amputation. She needs breast
reconstruction at appropriate time using myocutaneous flaps with
silicone implant

Post Burn Sequelae and their Management
501
Fig. 34.33A: A 15-year-old girl with post burn
contracture of right breast
Fig. 34.33B: Release and split skin graft done achieving normal
contours and size of breast (result after six years)
Fig. 34.34A: A 15-year-old girl with post burn contracture of left
axilla with apparently absent/undeveloped breast mound
Fig. 34.34B: Postoperative result after release of axilla and skin envelop
over the breast covered with split skin grafts. No augmentation was
required. Please note the symmetry with respect to size and contours
of both the breasts
Release alone versus Excision-release
Except for hypopigmented scars, which are de-epithelialized
and covered with thin grafts, scars need not be excised.
One should try to release and feed more and more of skin
graft. As the breast grows, the graft always falls short in
amount and another stage is needed. The hypertrophic scars
improve with time and ultimately blend with the grafted
areas and other scars due to spontaneously healed burns
over the breast. Most of these patients have contiguous
scars and/or contractures of the neck, axilla, and abdomen
etc. or have these areas split skin grafted during the
management of acute burns. Hence, the removal of scars
on the breast alone may not be of any significance. In general,
it is futile to excise scars and apply grafts as the patient is
given good aesthetics in contours only under the clothes.
Even excellently taken up and well settled grafts are bad
enough for the patient so as not to allow her to wear revealing
clothes. Vitiligo skin is a taboo in our Indian society.
Moreover, they may be visible through the clothes specially
when wet. Hence they need treatment especially in younger

502
Principles and Practice of Burn Care
Figs 34.35A to C: (A) A-14-years old girl with contracture of left axilla and apparently absent left breast mound and nipple-areola complex. (B
and C) Release and skin grafting were done for axilla and breast envelop. The breast envelop required release twice to accommodate the
enlarging breast mound. No augmentation was done. The operated breast appears slightly larger than the normal breast. Front view and lateral
view with arm abducted. Postoperative result after four years
Figs 34.35D and E: (D) Nipple being reconstructed with modified Little's quadrapod technique.
(E) Result after one week
age group. When the vitiligo scars are very limited, plenty
of donor sites are available and the surgeon is sure that their
replacement with a split skin graft will improve the cosmesis,
one can excise the scars in continuity with release incisions
and graft one larger area with sheet grafts. In patients with
extensive vitiligo scars on the anterior trunk, it may serve
no purpose by treating those on the breasts only. Once again,
the author would like to emphasize that the post burn patient
should be treated as a whole and not in bits and pieces.
Where to Place the Release Incision
The patient is examined with both arms by the side, then
abducted at right angles and finally full abduction with arms
parallel and by the side of the head. The position of nipple
and areola when present, its position with respect to opposite
NAC whether above or below, movement of the mound
with arm movements etc. all determine the site of release
incision. If the NAC is at proper position it is better to encircle
the areola and give long multiple darts in radial directions to
release the mound fully.
When release incisions are given, it is of utmost
importance that the surgeon does not cut into the mammary
gland. This is especially important in incisions made below
the areola where the breast fat and the inframammary
subcutaneous fat should be identified and the incision
deepened between the two. Fortunately the breast tissue
(fat) and the subcutaneous tissue over the ribs have different
A
B
C
D
E

Post Burn Sequelae and their Management
503
color, texture and appearance. Breast fat is lighter in color
(Fig. 34.37).
NAC Reconstruction48-52
NAC reconstruction is the final surgical step of breast
reconstruction. A large number of techniques have been
described and more are being reported. This proves that no
technique is totally satisfactory on a long-term basis. Some
may not be possible in every case. The biggest problem
with all the techniques is deterioration in nipple projection
or reduction in the height of the nipple.
Reconstruction of NAC in post burn cases differs from
that in post mastectomy cases in many respects.
Reconstruction of NAC is an integral part of post burn
reconstruction. This is because most of the post burn cases
are children and young adults in pre marriage age group
Figs 34.36A to C: (A) Post-burn contracture of both breasts with loss of left nipple areola complex. (B) Result after release and split skin graft
achieving normal contours and infra memory folds. (C) Areola reconstructed by tattooing (darker color has been used as compared to the color
of the opposite normal areola as the lighter color is not visible separately from the surrounding skin in our patients
Figs 34.36D and E: Final results with arms by the side and completely abducted, showing symmetrical size and
contours of breast and nipple areola complex
Fig. 34.37: Please note the lighter color and different texture of
breast fat in the upper part of the photograph
A
B
C
D
E

504
Principles and Practice of Burn Care
with a long life ahead of them. This is in sharp contrast to
post mastectomy patients most of whom are middle aged
or even elderly and are more concerned about survival and
cure from a dreaded disease rather than undergoing another
surgery for breast reconstruction. Also in post burn
reconstruction, an excellent mound is restored with rather
simple and short operations. It is but natural to complete
the reconstruction. It is also to be noted that many of the
techniques that give excellent results in post mastectomy
cases either give poor results or are not at all possible/
desirable in post burn reconstruction.
In unilateral cases, the goal of NAC reconstruction is to
match the opposite NAC with respect to site, size
(projection), shape, color and texture. In bilateral cases,
the aim is to restore NAC's which looks similar to each
other and to that of a normal female of that age and must be
situated at appropriate site. In cases, where the nipple is
apparently absent, an effort is made to find it out by pinching
the skin at various places, with spine flexed anteriorly and
arm adducted, over the probable site and finding out whether
the skin is tethered to underlying mound by ducts at any
place. If the site of nipple is found, the reconstruction of
NAC is done at this site. However if the site is not found,
the NAC is reconstructed at a site corresponding to the
opposite normal breast in unilateral cases or at appropriate
symmetrical site in bilateral cases.
Timing of NAC Reconstruction
NAC should be reconstructed only in a stable mound. If a
mound is still increasing in size or changing shape because
of normal pubertal changes or because of surgical
interventions, the reconstruction of NAC should be deferred
till the breast size appears normal for the physique of the
patient. An earlier reconstruction can be attempted when
the site of NAC on burnt breast is clearly shown by the
remnants of the NAC so that the surgeon does not have to
select the appropriate site. In cases where the NAC is
completely absent and the surgeon needs his own judgment
and measurements to find the site, the stability of the mound
assumes greater significance. One stage reconstruction of
the mound and the NAC is simply not possible in post burn
reconstructions.
In post burn reconstructions, if one breast is unburnt, it
is the author's firm belief that this breast must not be
interfered with for various functional, esthetic and sexual
reasons. Moreover, these patients being children and young
adults, the normal NAC is never too big to donate.
Reconstruction of Areola
A number of techniques have been described in literature to
reconstruct the areola in post mastectomy cases and have
been extrapolated to post burn reconstruction. Grafts have
been taken from upper medial thigh and labia minora for
their darker color as compared to normal skin. These
hyperpigmented areas become further pigmented on grafting
and may give appropriate color match in post mastectomy
cases. However, when the whole breast skin is burnt and
there are areas on the breast that have spontaneously healed
mixed with grafted areas, the color match of the existing
grafts and scars is not much different from these donor
areas and they do not stand out. Moreover, in unmarried
and adolescent girls even the upper inner thigh skin is of
same color as the rest of the thigh from where grafts have
earlier been harvested to resurface the post burn raw areas
or later to release the contracture of the breast mound. In
addition, the darkening of grafted skin, after its 'take', depends
on its exposure to ultraviolet light in early postoperative
period. This exposure is not there in these patients for
obvious reasons. The best technique that is applicable for
these patients is tattooing using appropriate colors inserted
deep intradermally53 (Figs 34.36A to E, 34.38A and B). More
than one stage is required and any fading at a later date may
need re-tattooing to augment the color. No donor site is
required and opposite breast is not interfered with.
Reconstruction of Nipple
This is the most difficult and frustrating part of post burn
breast reconstruction. It differs greatly from nipple
reconstruction in post mastectomy cases. Almost all the
techniques of nipple reconstruction have been described
primarily for post mastectomy cases and extrapolated
directly or with slight modifications to post burn cases.
Again, in almost all the described techniques, the
reconstructed nipple tends to loose height or projection over
a period of time. The availability of a very large number of
techniques is a testimony to the fact that none is universally
successful.
A number of techniques described for postmastectomy
cases are not possible/desirable in post burn cases. For
example, nipple sharing technique should not be used as
most of these patients are young and their nipple is not
large enough to donate. Moreover, one would not like to
spoil the only normal nipple in this age group. Composite
grafts from the ear lobule or toe pulp are bound to have an
unacceptably high failure rate because of the poor vascularity

Post Burn Sequelae and their Management
505
Two concentric circles of 1cm and 4cm diameter are
marked with their center at the site where nipple is to be
made. Three V-shaped areas are marked in the area between
two circles as shown for de-epithelialization. A cut is made
in the outer circle and deepened till and slightly into the
breast tissue. The de-epithelialized areas are closed by
stitching together the adjacent non de-epithelialized skin areas.
With a stay suture in the center of the smaller circle, the
newly formed nipple is pulled out and the raw area is grafted
with thick split skin graft using tie-over sutures.
Theoretically, this will give a projection of around 1.5 cm.
This over correction takes care of partial flattening over a
period of time. After the wounds have healed and the graft
settled, size of the areola required is marked with nipple as
the center and tattooing done to complete the NAC
reconstruction. This technique does not undermine any area
and is modified from Little's quadrapod technique54,55 (Figs
34.35A to E).
Another technique involves construction of two adjacent
'dog-ears' which together give a semblance of a papilla.
Three 1cm squares (A, B, B′) are drawn as shown in (Figs
34.39A to H) with square "A" over the site of nipple. Two
triangular areas are also marked in the vertical axis as shown.
Along with outer two squares B and B', the triangles are
thinly de-epithelialized. Two thick dermal flaps are raised
with their base towards the nipple, i.e. square "A" and
allowed to contract towards the latter. When stitching of
the raw areas is started from either apex, a dog ear forms
towards the square "A". The dog ears along with dermal
flaps help in forming a nipple at site "A".
Male External Genitalia (Penis and Testes)
Although penoscrotal region is very commonly burnt as
part of extensive burns, it is highly unlikely for a thermal
burn injury to result in loss of penis and/or testis. Contact
electrical burn injuries, on the other hand, are known to
result in a complete loss of penis and one or both the testes.
Their reconstruction is a must not only for restoration of
form and function but also for the psychosexual health of
the victim. However, one has to wait for the scars in the
region to become mature, soft and supple.
The reconstructive techniques for phalloplasty56-61 have
seen great advances since the time of Bogoras who reported
the first such operation in 1936. The penis being a tube
within a tube and the tube flap having been described by
Gillies during World War I, the penile restoration has seen
the transformation from multi-staged, random pattern tube
flaps to axial pattern musculocutaneous and fasciocutaneous
Fig. 34.38A: Post burn loss of left nipple areola complex. Note the
reconstructed nipple
Fig. 34.38B: Tattooing done to reconstruct areola
they get from the skin grafted areas. The techniques where
the nipple protrusion is obtained by burying a piece of
autologous conchal cartilage or Silastic implant etc. are not
desirable because of the risk of jeopardizing the vascularity
of overlying split skin graft. Many of the techniques
described using local skin flaps to reconstruct nipple
projection rely on the dermal and sub dermal base which
are highly deficient in skin grafted areas.
The only techniques which are possible are the one which
do not raise the local skin (actually skin graft) from its bed
so that the vascularity of the skin does not suffer. The author
reconstructs the nipple by the following techniques.

506
Principles and Practice of Burn Care
and then free flaps which even included nerves and bone to
provide sensation and stiffening. At present, state of the art
neurosensory fasciocutaneous free flaps are used to
reconstruct a phallus which is acceptable not only
functionally and cosmetically but also psychosexually.
For the last 25 years, the free radial artery forearm flap
has remained the flap of choice for phalloplasty. The basic
design consists of construction of a tube within a tube and
various modifications have been done to improve the
appearance and sensation and to decrease the complications.
The most important drawback of unsightly grafted donor
site in the forearm may not be of much concern to a burn
patient (compared to patients of gender re-assignment
surgery) as he already has plenty of such areas and scars
due to initial burn injury itself. However, as the flap is hairy,
Figs 34.39A to H: (A to E) Nipple reconstruction. Areolar tattooing done (F to H) See text for details
A
B
C
D
F
G
H
free ulnar artery forearm flap has been described in its place.
The use of fibular osteocutaneous flap for phallic
construction has been advocated to achieve rigidity.
The photographs (Figs 34.40A to I) show the staged
reconstruction of phallus of a burn victim using a bipedicled,
tubed extended groin flap. The urethra has been made from
the in-turning of non-hairy skin in the long axis of the center
of the flap while the remainder of the flap skin is de-
epithelialized. The dimensions of the flap are based on the
length of penis desired (15 cm approx.) and width is based
on the maximum donor site which can be closed primarily
by undermining and advancement with hip flexed. The outer
tube is made by stitching the flap margins together over the
urethra in such a way that the undersurface of the groin
flap forms surface of the outer tube. This necessitates the
E

Post Burn Sequelae and their Management
507
covering of the raw area with a split skin graft. When the
graft and the tube have matured over a period of 3-4 months,
division and inset over the region of native penis is started.
The use of graft to make the skin of the neophallus lends it
some rigidity by virtue of secondary graft contraction.
The silicone testicular implant(s) may be inserted into
scrotal skin, if available, or the scrotum is reconstructed
from locally available flaps from the upper inner thigh.
Amputations
Electrical contact burn injuries are known to kill the victim
instantaneously. The 'fortunate' survivors very commonly
end up in multiple and major amputations at various levels
leading to a lifelong disability to the victim and a liability on
the family and the society. Contact with high tension wires
often leads to gangrene of one or more limbs. Circumferential
Figs 34.40A to I: Post burn loss of penis in a 30-year-old. Reconstruction done in stages by constructing tube in tube from groin region.
Patient passing urine normally (Markings on a model)
A
D
E
F
G
H
I
C
B

508
Principles and Practice of Burn Care
full thickness burns of the extremities with tight eschar, if
not treated timely by appropriate escharotomy incisions,
may also end up in distal gangrene necessitating
amputation(s).
Most of these patients with amputations at higher levels
in upper and lower limbs are offered prosthesis to improve
function as well as overall appearance. These patients may
have stump instability, poor soft tissue coverage over the
bone end, joint contracture, atrophic scars, painful neuromas
or improper stump length etc. which may pose difficulties
in fitting the prosthesis. These problems must be addressed
to achieve successful rehabilitation. In upper limb if thumb
alone is lost, 'pollicization' of index finger may be done.
Microvascular transfer of great or second toe to reconstruct
the thumb can give excellent function and cosmesis. Web
spaces may be deepened and 'phalangisation' done.
CHRONIC UNHEALED AREAS
In India and other developing nations, the only treatment
received by a large number of burn patients is in the form
of simple dressings with some of the commonly available
antibacterial creams or even indigenous substances. These
patients heal by contracture formation. However, some
chronic raw (unhealed) areas may remain over non-joint
regions after all the natural limits of the force of contraction
have been exhausted (Figs 34.41A to 34.42B). Typically,
these areas are over the rib cage, long bones and calvarium
etc. Depending on the time that has elapsed between the
date of burn and reaching a burn surgeon, the wound bed
has more and more of fibrous tissue and consequently poor
vascularity. These areas have pale granulation tissue and do
not accept split skin grafts well. They may need excision of
all the fibrous tissue down to soft and supple healthy bed
for a complete graft 'take'. In the scalp region and over the
subcutaneous bones, the bed may be formed of the dried
up bone which needs chiseling till bleeding bone or diploe in
the case of calvarium before wound closure with skin graft
or flap.
BONE AND JOINT DEFORMITIES
A burn injury may lead to a number of musculoskeletal
deformities even if the burn injury was no more than skin
deep. Many of these deformities are due to the strong
contractile forces which tend to heal a full thickness burn
injury in the absence of skin grafting (Figs 34.43A and B).
When the burns are sustained in early childhood and not
treated appropriately, the deformities get accentuated with
A
B
Figs 34.41A and B: Chronic raw areas over lateral arm, shoulder
and scapular region along with contracture neck
A
B
Figs 42A and B: Chronic raw areas over shoulder, scapula and
lateral rib cage where healing by contracture formation is not possible
along with post burn contracture of neck, axilla and elbow

Post Burn Sequelae and their Management
509
growth of the child. Thus, the joints may be subluxated or
dislocated. The bones and joints may bend in an abnormal
direction. When such patients come to a plastic surgeon
after many years in late teenage or adulthood, it may not be
possible to release the joint contracture not only because of
shortened musculoskeletal units but also because the
growing age has moulded the bone and joint in an abnormal
position. Post burn contractures on the dorsum of hand
may spoil the extensor apparatus giving rise to deformities
like Boutonnière, swan-neck etc. When untreated for a long
time, there may be irreversible damage to the joints of hand
and permanent life long deformities result.
Severe mentosternal contractures in children may lead
to deformities of mandible, alveolus and teeth with disturbed
occlusion.62,63
DEVELOPMENT OF MALIGNANCY
Once the reconstructive surgery of the burn patient is over,
all the scars have well settled and matured and the patient
has returned back to society, these patients are at risk of
development of malignancy even after many decades64-66
(Figs 34.44A to 34.47E). The fact that thermal burn scars
can degenerate and develop into malignancy was known to
Celsus in 100 AD. Jean Nicholas Marjolin has been widely
acknowledged as to provide with the first description of
skin cancers in post burn scars in 1828. However, it was
De Costa in 1903 who coined the term "Marjolin's ulcer'
and applied it to tumors arising in simple leg ulcers. Some
workers have doubted whether Marjolin really recognized
the malignant nature of these ulcers. In addition, while some
authors restrict the use of the term Marjolin ulcer for
malignancy arising out of burn scars only, others use the
term for malignant tumors arising in other cutaneous scars,
chronic venous ulcers, sinuses of chronic osteomyelitis,
pressure sores, scar tissue around colostomies, frost bite
etc. as well. In 1930, Treves and Pack67 presented an
excellent analysis on the development of cancer in 34 burned
patients. They observed 2% burn scars undergoing a
malignant change with extremities and scalp being affected
most commonly.
The exact mechanism whereby a malignant change
occurs in a post burn scar is still not known. It has been
observed that a cutaneous scar subjected to continuous
irritation has increased potential for malignant change. Slow
initial healing and scar instability are very important in the
development of cicatricial cutaneous malignancies. Repeated
trauma, when applied to any tight or thickened scar situated
over the joints, is an important factor in neoplastic change.
The relationship between skin cancer and repeated/prolonged
thermal injury is best exemplified by two unique examples
of 'Kangri' cancer in India and 'Kairo' cancer in Japan.68
The 'Kangri' is an earthenware bowl heated by charcoal
and worn against the skin of the abdomen and thighs for
warmth by Kashmiris in India. In the 'Kairo' burn cancer of
Japan, the person keeps a light tin box (with hot coal inside)
that fits snugly against abdomen for at least three hours at a
stretch to keep warm. Owing to the continued application
of heat, the skin in these areas becomes dry and horny and
shows chronic dermatitis leading to malignant neoplastic
changes.
Post burn skin cancers are very slow to grow and
metastasize as has been observed and reported by a number
of workers. Most patients are free of regional or distant
Figs 34.43A and B: Deformed mandible with severe malocclusion
due to untreated mentosternal contracture following burns sustained
in very early childhood
A
B

510
Principles and Practice of Burn Care
metastasis at the time of presentation. Once the tumor breaks
into the surrounding normal skin or is excised, there is a
high incidence of local recurrence and regional/distant
metastasis. This has led some workers to suggest the theory
(although unproven) of Marjolin's ulcers developing in an
'immunologically privileged site'.69-71 The presence of
relatively avascular dense scar tissue and almost absent/
obliterated lymphatics allows the primary tumor to grow
unrestricted by host immunological mechanisms. This
significant delay may be the reason of the tumor's aggressive
behavior once the malignant tumor cells reach the lymph
nodes as this is their first encounter with the immune system.
The most common malignant neoplasm to develop in
post burn scars is the squamous cell carcinoma (SCC) with
basal cell carcinoma(BCC) being the next. Of the 1091SCC's
studied by Treves and Pack, 21(1.92%) arose in post burn
scars. Seven BCC's arose in burn scars out of 1374 cases
studied (0.51%). There are a number of case reports of
various other cancers including sarcomas developing in post
burn scars.72 Thus, melanoma, adenocarcinoma,
liposarcoma, leiomyosarcoma, fibrosarcoma, malignant
fibrous histiocytoma, even extraskeletal osteogenic
carcinoma, malignant schwannoma, etc. have all been
reported. The relatively deep position of mesenchymal cells
of the dermis and subcutaneous tissues making them less
vulnerable to trauma and their lesser tissue regeneration than
the superficial epidermis has been put forward as the
explanation for rarer occurrence of sarcoma as compared
to carcinoma in burn scars. Marjolin's ulcer is three times
more common in men as compared to women. Roughly, it
involves lower limbs, head and neck, upper limbs and trunk
in a ratio of 4:3:2:1. All post burn cicatricial malignancies
develop with a prolonged latent period, i.e., the time interval
between the acute burn injury and the onset of malignancy.
This period has been reported to vary from 8 to 63 years
with a mean of 32.5 years by Treves and Pack (1930).
Figs 34.44A to F: 21 year female with squamous cell carcinoma of scalp arising in postburn scars. Treated with wide excision and local
transposition of remaining scalp and split skin graft
A
B
C
D
E
F

Post Burn Sequelae and their Management
511
Rarely, early arising Marjolin ulcer cases have been reported
with a latent period of one year or less.73 In addition, the
latent period has been found to be inversely proportional to
the patient's age at the time of burn, i.e. the younger the
victim at the time of burn, longer is the interval for malignant
change. Older the patient, shorter is the latent period.
The post burn scar malignancies are to a great extent
preventable. Indeed, their incidence has certainly decreased.
This is because of the early treatment of unstable and tight
Figs 34.45A and B: 38 years old male with squamous cell carcinoma
over anterior ribs arising in post-burn scars treated with wide excision
and split skin graft
A
B
Figs 34.46A and B: (A) Squamous cell carcinoma arising out of post
burn scar in popliteal fossa region. (B) Wide exicision and split skin
grafting done. Result after two months
scars and ulcers especially over the joints where repeated
trauma occurs. The grafted as well as spontaneously healed
burnt areas must be kept soft and supple by application of
bland oils and creams. Once the acute as well as
reconstructive treatment is over, all patients must be advised
to report any ulceration at the earliest. Any patient presenting
with a non-healing ulcer in an earlier healed burn area must
be looked upon with suspicion and subjected to excision
biopsy. The contracting bands must be released and the
area split skin grafted.
Treatment of biopsy proved malignancy depends on the
histopathological type and the status of lymph nodes
draining the area. For squamous cell and basal cell
carcinomas, a wide local excision with a 3-4 cm margin of
normal skin and including the muscle fascia should be done.
Although some workers have done prophylactic lymph node
dissection, most recommend this surgery only when they
are palpable. It is to be noted that the enlarged lymph nodes
palpable at the time of initial presentation may be due to
chronic infection. Fine needle aspiration cytology (FNAC)
examination may be done after a course of broad spectrum
oral antibiotics. The nodes tend to settle after the local
wound heals in 2-4 weeks time. A regular life-long follow
up is essential because metastatic recurrences are common
within a 3-year period. Squamous cell carcinomas arising
in burn scars have always been considered as more
aggressive than arising otherwise. Poor prognostic features
are lymph nodal involvement and local extension of disease
at the time of presentation. Involvement of the regional lymph
nodes is followed by metastasis to brain, liver, kidney and
lungs. Lower extremity lesions have higher rates of nodal
metastasis. A patient who is metastasis free for three years
has an excellent prognosis. Malignant lesions which involve
deeper structures like bone and joint are treated by
amputations at appropriate levels.
The management of the rare sarcomas in burn scars is
no different from those which arise without any such history
of burn or other scar.
MISCELLANEOUS
It is said that a major burn is a systemic disease and affects
the physiology of each and every system in the body. It is
not surprising, therefore, that the list of post burn sequelae
is almost unending and cannot be classified adequately. Each
and every sequela described in the vast burn literature cannot
be covered even in a book devoted to same. A number of
problems must, therefore, have been left out in this chapter.
A
B

512
Principles and Practice of Burn Care
Figs 34.47A to E: (A) Squamous cell carcinoma arising in a post burn scar at right elbow region with contracture. (B) Wide excision and
release done. (C and D) Views of the resected specimen. (E) Postoperative result
A
C
B
D
E

Post Burn Sequelae and their Management
513
For example, electrical burns are known to lead to cerebral,
spinal and peripheral nerve injuries with a long latent interval
between the injury and the neurological dysfunction or
deficit. They may cause hemiplegia, quadriplegia, paraplegia
and neuropathies. These patients need the consultation of a
specialist neurologist or neurosurgeon. Cataract can also
occur requiring an ophthalmologist's intervention.
Heterotopic ossification or myositis ossificans is a rarely
encountered complication of burns. Although elbow is the
most common region involved, shoulder, hip and knee may
also be affected and require surgical treatment by an
orthopedic surgeon. Respiratory and inhalational burn injuries
may lead to long term lower respiratory tract instability and
need management by a respiratory physician.
PSYCHOLOGICAL DISORDERS
Beyond physical sequelae, a burn injury can also result in
severe psychological and emotional distress due to the
traumatic event itself and due to the scarring and deformities
left even after the exhaustion of a plastic surgeon's
armamentarium. It is said,"Time is a great healer". A burn
surgeon realizes the truth of this statement not only in the
healing of even extensive wounds but also in the recovery
from emotional trauma. However, scars whether physical
or psychological do remain to a greater or lesser extent. In
contrast to other injuries and adult victims, the burn injuries
in children do cause psychological problems in parents as
well. This is because of their concern for the child's future,
especially with respect to finding a suitable match, when
they grow up. Not only for victims who have post burn
sequelae on the face is it difficult to find a match but also
for patients who have scars in usually covered areas
especially on the breasts as this fact cannot be disclosed to
all prospective life partners. Parents of girls in marriageable
age group do move from one plastic surgeon to another in
the hope that some 'cosmetic surgery operation' may solve
their problem or at least there must be some cream or lotion
the application of which will fade away the scars. The large
number of proprietary creams available in the market for
the purpose and their high turnover in amount of cream and
money is a testimony to the fact that the patient and their
parents are ready to do anything to achieve scar less skin.
Expression of inability to do any further by the plastic surgeon
leads to depression.
SUMMARY
The burn is a devastating injury with a lot of immediate
morbidity and mortality to the victim, great financial
implications to the patient, his/her family and to the
government and an unending list of post burn sequelae and
the ever changing improvements in techniques to manage
them. Full textbooks have been devoted to the management
of post burn sequelae 74, 75 apart from the vast literature
available. This chapter attempts to present the commonest
problems and principles of their management over which
the reader can build up from his own experience and study
of further literature.
REFERENCES
1. Brown AS, Barot LR. Biologic dressings and skin substitutes Clin
Plast Surg 1986;13:69-74.
2. Klein MB, Donelan MB, Spence RJ. Reconstructive Surgery J. Burn
Care Res 2007;28:602-05.
3. Maria da Luz, Ferreira B. Tissue expansion in the reconstruction of
burn sequelae Ann. of Burns and Fire Disasters 2002;Vol.XV:
138-41.
4. Motamed S, Niazi F, Atarian S, Motamed A. Post burn head and
neck reconstruction using tissue expanders Burns 2008;34:878-84.
5. L'Orenzi FD, Hulst RV, Boeckx W Free flaps in burn reconstruction
Burns 2001;27:603-12.
6. Lineres HA. Pathophysiology of the burn scar. In DN Herndon (Ed)
Total Burn Care. Philadelphia, WB Saunders Co 1996;383-97.
7. Poh-Fitzpatrick, MB. Skin care of the burned patient. Clin Plast
Surg 1992;19:745-51.
8. Su CW, Alizadeh K, Boddie A, Lee RC. The problem scar. Clin Plast
Surg 1998;25:451-65.
9. Chavapil M, Koopmann C Scar formation: Physiology and
pathological states. Otolaryngol. Clin North Am 1984;17:265-72.
10. Robson MC, Barnett RA, Leitch IOW, Hayward PG Prevention
and treatment of post burn scars and contracture. World J Surg
1992;16:87-96.
11. Jackson DM. The diagnosis of the depth of burning Br. J Surg
1953;40:588-96.
12. Grover R, Morgan BDG. Management of hypopigmentation
following burn injury Burns 1996;22:627-30.
13. Schneider JC, Holavanahalli R, Helm P, Goldstein R, Kowalske K
Contractures in burn injury: Defining the problem J. Burn Care Res
2006;27:508-14.
14. Leblebici B, Adam M, Bagis S, Tarim AM Noyan T, Akman MN,
Haberal MA. Quality of life after burn injury: the impact of joint
contracture J. Burn Care Res 2006;27:864-68.
15. Cohen IK, Diegelmann RF, Lindblad WJ. Wound Healing:
Biochemical and clinical aspects. Philadelphia, WB Saunders Co.
1992.
16. Fine NA, Mustoe TA. Wound Healing In LJ Greenfield, MW
Mulholland, KT Oldham, GB Zelenock and KD Lillemoe (Eds.)
Surgery: Scientific Principles and Practice 3rd Edition. Philadelphia,
Lippincott Williams and Wilkins Publishers 2001;431-49.
17. Donelan MB. Reconstruction of the burned hand and upper
extremity. In J.G.McCarthy (Ed.) Plastic Surgery, Vol. 8.
W.B.Saunders Co. Philadelphia 1990;5452-82.
18. German G, Philipp K. The burned hand In Green's Operative Hand
Surgery 5th Edition, Elsevier, Philadelphia 2005;2159-90.

514
Principles and Practice of Burn Care
19. Harrison CA, MacNeil S. The mechanism of skin graft contraction:
An update on current research and potential future therapies Burns
2008;34:153-63.
20. Klasen HJ. Skin grafting. In JAD Settle, (Ed) Principles and Practice
of Burns Management. London, Churchill Livingstone 1996;289-
303.
21. Iwuagwa FC, Wilson D, Bailie F. The use of skin grafts in burn
contracture release: a 10-year review Plast. Reconstr Surg
1999;103:1198-204.
22. Rudulph R, Ballantyne DL. Skin Grafts. In JG McCarthy (Ed) Plastic
Surgery, Vol 1. W.B.Saunders Co. Philadelphia 1990;221-74.
23. Kischer CW, Shetlar MR, Shetlar CL. Alteration of hypertrophic
scars induced by mechanical pressure Arch. Dermatol 1975;111:60-
64.
24. Ward RS. Pressure therapy for the control of hypertrophic scar
formation after burn injury. A history and review J Burn Care
Rehabil 1991;12:257-62.
25. Cara Collins JA. Pressure techniques for the prevention of the
hypertrophic scar. Clin Plast Surg 1992;19:733- 43.
26. Sawada Y. Pressure developed under pressure garments Br J Plast
Surg 1993;46:538-41.
27. Macintyre L, Baird M. Pressure garments for use in the treatment
of hypertrophic scars: a review of the problems associated with
their use Burns 2006;32:5-10.
28. Leman CJ Splints and accessories following burn reconstruction.
Clin Plast Surg 1992;19:721-31.
29. Cooper R, Hall S. Occupational Therapy and physiotherapy. In
Settle, JAD (Ed) Principles and Practice of Burns Management.
London, Churchill Livingstone 1996;453-64.
30. Kerckhove E V, Stappaerts K, Boeckx W, Hof BV, Monstrey S,
Kelen AV, Cubber JD. Silicones in the rehabilitation of burns: a
review and overview Burns 2001;27:205-14.
31. Casaer M, Kums V, Wouters PJ, Van den kerckhove E, Berghe GV.
Pruritis in patients with small burn injuries Burns 2008;34:185-91.
32. Brooks JP, Malic CC, Jadkins KC. Scratching the surface-Managing
the itch associated with burns: A review of current knowledge Burns
2008;34:751-60.
33. Srivastava JL, Biswas G, Narayan RP, Goel A. Chronically exposed
calvarium following electrical burns Burns 1993;19:138-41.
34. Motamed S, Davami B. Eyebrow reconstruction following burn
injury Burns 2005;31:495-99.
35. Omranifard M, Mehrabi Koushki A Comparison of four surgical
methods for eyebrow reconstruction Indian J Plast Surg
2007;40:147-52.
36. Rohrich RJ, Barton FE. Hollier Nasal Reconstruction In Grabb and
Smith's Plastic Surgery, SJ Aston, RW Beasley, CHM Thorne
(Editors)5th Edition Lippincott Raven Publishers, Philadelphia
1997;513-28.
37. Sawhney CP. Reconstruction of partial loss of nose Clin Plast Surg
1981;8:521-34.
38. Tsur H, Shafir R, Orenstein A. Hair bearing neck flap for upper lip
reconstruction in the male Plast Reconstr Surg 1983;71:262.
39. Walton R L, Bunkis J. A free occipital hair-bearing flap for
reconstruction of the upper lip Br. J Plast Surg. 1983;36:168.
40. Lyons GB, Milroy BC, Glenovay P, Teston LM. Upper lip
Reconstruction: Use of the free superficial temporal artery hair-
bearing flap Br J Plast Surg 1989;42:333-36.
41. Kumar P. L-shaped scalp flap for moustache reconstruction in a
patient with an acid burn of the face Burns 1996;22:413-16.
42. Hafezi F, Naghibzadeh B, Nouhi AH Facial reconstruction using the
visor scalp flap Burns 2002;28:679-83.
43. Brent BD. Reconstruction of the ear In Grabb and Smith's Plastic
Surgery, SJ Aston, RW Beasley, CHM Thorne (Editors)5th Edition
Lippincott Raven Publishers, Philadelphia 1997;413-30.
44. Bhandari PS. Total ear reconstruction in post burn ear deformity
Burns 1998;24:661-70.
45. Neale HW, Smith GL, Gregory RO, MacMillan BG. Breast
reconstruction in the burned adolescent female(an 11-year,157
patient experience Plast. Reconstr. Surg 1982;70:718-24.
46. MacLennan SE, Wells MD, Neale HW. Reconstruction of the burned
breast Clin Plast Surg 2000;27:113-19.
47. Foley P, Jeeves A, Davey RB, Sparnon AL Breast burns are not
benign: Long term outcome of the burns to the breast in prepubertal
girls Burns 2008;34:412-17.
48. Brent B, Bostwick J. Nipple-areola Reconstruction with auricular
tissues. Plast Reconstr Surg 1977;60:353-61.
49. Broadbent TR, Woolf RH, Metz PS. Restoring the mammary areola
by a skin graft from the upper inner thigh. Br J Plast Surg
1977;30:220-22.
50. Gruber RP. Nipple-areola reconstruction: a review of techniques.
Clin Plast Surg 1979;6:71-83.
51. Abdel-Khalek AH. Post burn nipple reconstruction with modified
fish tail flap Annal.Burn Fire Disasters XVI: 2003;146-50.
52. Schwartz AW Reconstruction of nipple and areola. Br J Plast Surg
1976;29:230-33.
53. Masser MR, Di MeoL, Hobby JAE. Tattooing in the reconstruction
of the nipple and areola: A new method Plast Reconstr Surg
1989;84:677.
54. Little JW, Munasifi T, McCulloch DT. One-stage reconstruction of
a projecting nipple: the quadrapod flap. Plast. Reconstr. Surg.
1983;71:126-32.
55. Little JW. Nipple areolar reconstruction Adv.Plast Reconstr Surg
1986;3:43-79.
56. ChangTS, Hwang YW. Forearm flap in one-stage reconstruction of
penis Plast. Reconstr. Surg. 1984;74:251-58.
57. Biemer E Penile reconstruction by the radial arm flap Clin Plast
Surg 1988;15:425-30.
58. Davies DM, Matti BA. A method of phalloplasty using the deep
inferior epigastric flap Br J Plast Surg 1988;41:165-68.
59. Gottlieb LJ, Pielet RW, Levine LA. An update on phallic construction
Advances in Plastic and Reconstructive Surgery 1994;10:267-83.
60. Gilbert DA, Schlossberg SM, Jordon GH. Ulnar forearm phallic
construction and penile reconstruction Microsurgery 1995;16:314.
61. Yavuz M, Dalay C, Kesiktas E,Ozerdem G, Kesiktas NN,
Acarturk S Contact high-tension electrical burns to the penis:
Reconstruction of the defect with free radial forearm fasciocutaneous
flap and silicone rod, a case report Burns 2006;32:788-91.
62. Masson CL, Janvier H. Dentomaxillofacial deformities following
cicatricial retractions of neck, sequelae of burns in childhood Ann
Chir Plast 1972;17:254-59.
63. Nahlieli O, Kelly JP, Baruchin AM, BenMeir P, Shapira Y
Oromaxillofacial skeletal deformities resulting from burn scar
contractures of the face and neck Burns 1995;21:65-69.
64. Arons MS, Lynch JB, Lewis SR, Blocker TG. Soft tissue carcinoma
Part I A Clinical Study with Special Reference to Burn scar carcinoma
Ann Surg 1965;161:170.
65. Novick M; Gard DA Hardy SB, et al. Burn scar carcinoma: Review
and analysis of 46 cases J Trauma 1977;17:809-17.

Post Burn Sequelae and their Management
515
66. Malheiro E, Pinto A, Choupina M, Barroso L, Reis, Amarante J.
Marjolin ulcer of the scalp: Case report and literature review Ann.
Burn and Fire Disasters 2001;vol. XIV no.1:39-43.
67. Treves N, Pack GT. The development of cancer in burn scars Surg.
Gynecol. Obstet 1930;51:749-782.
68. Chowdri NA, Darzi MA Post burn scar carcinomas in Kashmiris
Burns 1996;22:477-82.
69. Castillo JL, Goldsmith HS. Burn malignancy in a possible depressed
immunologic setting Surg. Forum 1968;19:511-13.
70. Futrell JW, Myers GH. The burn scar as an immunologically privileged
site Surg. Forum 1972;23:129-31.
71. Boswick J, Jefferson Pendergrast W, Vasconez LO. Marjolin's ulcer:
an immunologically privileged tumor Plast. Reconstr. Surg
1976;57:66-69.
72. Fleming RP, Rezek PR. Sarcoma developing in an old burn scar Am
J Surg 1941;54:457.
73. Celik E, Eroglu S, Karagaoglan N, Uzunismail A. Early arising
Marjolin’s ulcer in the scalp Ann. Burns and Fire Disasters
2003;XVI(4);217-20.
74. Achauer, BM. Burn Reconstruction, New York, Thieme Medical
Publishers. 1991.
75. Sood R, Achauer BM. Achauer and Sood's Burn Surgery
Reconstruction and Rehabilitation. Saunders, Elsevier. 2006.

516
Principles and Practice of Burn Care
Medicolegal Aspects of
Burn Injuries
35
Chandrakant, Sujata Sarabahi
Chapter
INTRODUCTION
Fire has played a multipurpose role in the Indian history. It
has been used not only for cooking food but also for religious
purposes (like ‘havans’ and ‘sati’), blessing couples during
marriage ceremonies and also for sterilizing instruments for
surgery (Sushruta). Over the years, it has been very often
misused for committing homicide or suicide or even for
destruction of evidence of the crime committed. Even
though ‘dowry deaths‘ due to causes other than burns were
prevalent in the West in the middle ages, ‘bride burning’ or
‘dowry deaths’ has continued to plague the Indian society
even in the twenty first century. Thus, burns in any female
within seven years of marriage are considered significant
and culpable before the law until proved otherwise.
The Webster’s dictionary of English language has
described ‘Burns’ as the injuries caused by application of
dry heat, moist heat, abnormal cold, chemicals substances,
poison, electricity or lightening and characterized by
reddening, blistering or charring. For medicolegal purposes,
injuries caused by lightening, electricity, X-rays, radiation,
friction of body tissues, ultraviolet radiation are also included
into burn injuries.
Scalds are a kind of burn injuries resulting due to the
application of liquid object, usually hot water and other
liquids at or near their boiling point or from steam. There is
no singeing of hair or charring of tissues. It resembles like
a first degree burns showing reddening with formation of
blisters with different shape and size, with well defined,
demarcated line of differentiation. If punctured, there is a
red base.
Chemical burns are caused by corrosive substances like
acids or alkalies, characterized by redness of skin, formation
of ulcers, acute inflammation and discoloration and staining
of skin.
CLASSIFICATION OF BURNS
There are four types of classifications usually used for burns.
Dupuytren’s Classification
Dupuytren has divided the burn injuries into six degrees
depending upon the loss of external and internal tissues of
the body.
1st Degree Burns: There is simple redness of skin,
erythema and after healing there is no scar formation.
2nd Degree Burns: There is acute inflammation and also
formation of blisters. After healing, there is no scar
formation. Burns are very painful.
3rd Degree Burns: There is destruction of cuticle and
part of true skin and subsequently healing results in
formation of scars.
4th Degree Burns: There is loss of whole skin with loss
of nerve endings. After healing, there is formation of scars.
But burns are not painful.
5th Degree Burns: There is loss of deep fascia, internal
tissues and at the time of healing there is formation of scars,
associated with deformities.
6th Degree Burns: There is charring of external and internal
tissues with injuries to whole limbs including bones and
other organs of the body.
This classification is not accepted any longer because it
is difficult to differentiate the various degrees by naked eye
and they do not relate well to the prognosis.

Medicolegal Aspects of Burn Injuries
517
Wilson’s Classification (Modern Classification)
Wilsons classification is also known as modern classification
where Dupuytren’s classification has been grouped into
three types of nomenclature:
i. Epidermal (1st and 2nd Degree Burns): The burned
part is red and there is formation of blister which is
covered by pale, avascular epidermis surrounded by
a thin bright area of inflammation, but on healing no
scar formation results.
ii. Dermoepidermal (3rd and 4th Degree Burns):
There is loss of cuticle and part of true skin (whole
thickness). On complete healing, there is formation
of scars. These types of burns are very painful due to
the irritation of nerve endings surrounding the affected
tissues.
iii. Deep (5th and 6th Degree Burns): There is charring
of external and internal tissues including bones with
destruction of nerve endings. Burns are relatively less
painful. Healing results in formation of scars,
contractures and deformities.
Rule of Nine Classification
Surgical classification also known as Hebras classification
or Rule of Nine—depending upon the estimation of
percentage of body surface burnt. The whole body is taken
as 100% and each part of the body is given 9% or multiple
of 9% as follows:
Part of Body
% of Body Surface
Head and neck
9%
Right upper limb
9%
Left upper limb
9%
Right lower limb
18%
Left lower limb
18%
Anterior trunk
18%
Posterior trunk
18%
Perineum
1%
Total
100%
Clinical Classification for Medicolegal Purposes
According to this classification, depending upon the
destruction or damage to epidermis or dermis, burns are
grouped into two categories:
i. Partial thickness burns: When there is loss of
epidermis and part of dermis. These burns are very
painful.
ii. Full thickness burns: When there is loss of whole
of epidermis and dermis. These burns are painless.
EFFECTS OF BURNS
Effects of burns mainly depends on the following factors:
a. Duration of exposure: Greater the duration of exposure
more severe are the burns
b. Age: Young children, infants and older individuals suffer
from burns more severely than adults
c. Temperature: Higher the temperature greater the
damage and severe the burns as the human skin is
tolerant to a very narrow range of external temperatures,
usually between 20°C and 44°C. Lower temperatures
which can be tolerated for short periods can cause burns
if exposure is prolonged. Similarly an object at 44°C
can cause burns if applied for five hours or more. On
the other hand, at 60°C, only 10 seconds exposure is
sufficient to cause a burn injury. ‘Kangri burns’ are very
commonly seen in Kashmiris due to the close contact
of lower abdomen with cisterns called “kangris” for the
purpose of warmth.
d. Extent and Part of Body: Surface area and part of the
body are more important than the degree of burns. Burns
on the head, neck, trunk and genitals are relatively more
dangerous than on other parts of body.
OBJECTS PRODUCING BURNS
Object producing burns are: (a) Highly heated solid objects
or molten metal, (b) Flames causing singeing of hairs,
blackening of skin, (c) kerosene oil, petrol, etc. produce
sooty blackening, (d) Explosives produce tattooing and
blackening, (e) X-ray and radiation causes redness of the
skin with shedding of hairs and pigmentation of the
surrounding skin, (f) Ultraviolet rays causes acute
eczematous dermatitis and (g) Corrosive substances cause
ulcerated patches.
For a forensic expert causative agent is required to be
known after death, so that based on the details of the
appearance the causative agent can be identified with
certainty.
The commonest burns all over the world are the ones
sustained due to dry heat which cause damage due to
conduction or radiation. If applied beyond a certain time,
they cause charring or coagulative destruction in the body.
Burns from flames usually leave shadow areas of unaffected
skin like in the creases (axilla, groin), which are spared
from direct exposure.
If exposure to flames is for very short duration, only
the tips of the hair all over the body are singed (eyelashes,
eyebrows, pubic and scalp hair). The melting of the keratin
in the distal end of the hair and its resolidification on cooling

518
Principles and Practice of Burn Care
leaves a blob on the end of the hair shaft. If the duration of
exposure is prolonged, there is complete burning of the
hair.
Corrosive burns: Corrosive burns are rarely accidental.
Usually they are associated with a homicidal intent, as seen
in the Indian scenario. Death due to corrosive burns is
uncommon and homicidal attacks are done with the intention
to maim the victim and not to kill. The most common agent
used is sulfuric acid which is also called ‘Oil of Vitriol’ and
the act is, therefore, called “Vitriolage”.
The burns due to acids and alkalis usually give a trickle-
like pattern. The nature of injury produced in the skin is
usually typical for different corrosive agents and hence the
appearance of the wounds is an indication for the nature of
the causative agent. Sulfuric acid-destroyed areas show a
grey or black appearance; nitric acid produces yellow brown
discoloration of the skin. Strong alkalis react with skin and
tissue lipids to give the wounds a soft, slippery and slimy
look which is initially grayish and later on attain a brown
tinge. Prolonged exposure to petrochemicals like kerosene
and petrol results in blistering. The blisters are initially
creamish and turn yellow after a short time.
If burns are due to splashing of hot liquids, a trickle
pattern is seen which indicates the posture of the patient at
the time of contact. The worst scalds are seen in the area
of initial contact and it decreases in intensity as the cooling
liquid flows away. Whereas, in case burns are due to
immersion in hot liquids, the severity of damage is uniform
till the sharply demarcated margin. Scalds do not cause
singeing of surface hair as in case of burns due to dry heat.
THE BURN INDEX
This index system was developed by the Brook Army
Medical Centre, Burn Unit of the US Army, for ascertaining
the effectiveness of treatment and prognosis of burns.
According to this system 0.5 point is denoted for each
percent area of second degree and 1 point for each percent
of third degree burns. At about 45 points, the mortality rate
is calculated to be approximately as 50%.
ANTEMORTEM AND POSTMORTEM BURNS
(FIGS 35.1 TO 35.4)
Many times, burnt or charred bodies are discovered and
the question arises whether the victim succumbed to burns
or otherwise. He or she may have died due to inhalation of
toxic fumes or due to some other reason like strangulation
or other violent acts and then burned later. It is, therefore,
essential to differentiate the antemortem burns from
postmortem burns by their characteristic features (Table
35.1)
Postmortem heating of body may mimic the antemortem
appearance. Postmortem drying of weeping serum in a burnt
area may lead to parchment like surface which can be
mistaken for third degree burn. If the skin actually catches
fire black brittle masses of dead burnt skin are formed under
which the muscles also may show a cooked appearance.
Muscle contractures from prolonged heat exposure are
always a postmortem finding since cooking of muscle is
incompatible with life. This is more commonly seen in the
flexor muscles which produces a ‘boxer’s ‘or pugilistic
attitude. On the other hand, contracture of paraspinal
muscles produces opisthotonus.
Postmortem electric burn marks appear similar to
antemortem electric burn marks except that they lack the
vital flare and erythematous changes. Postmortem electric
burns may be so severe to give a cooked muscle appearance.
Besides these, there are certain postmortem artifacts
seen in burn cases which are as follows; Postmortem
external wounds: Skin, if heated after death, contracts
markedly leading to splits in the body surface called ‘heat
ruptures’ which mimic antemortem wounds and are seen
on the extensor and flexor surface of the joints. Though
these may be seen following forceful attempt to straighten
a limb after death. They can, however, be differentiated
from the antemortem wounds by absence of bleeding in the
deeper tissues but it may be difficult if the burns are very
deep and involve the deeper tissues also.
Heat hematoma: This is found following prolonged
application of intense heat to the head which causes the
brain to compress into a cooked mass, the dura may split
and blood may boil out of the diploe or venous sinuses as a
chocolate brown spongy mass. At times, even the brain
may ooze out as a frothy paste. The skin as well as underlying
skull bones may be totally charred. These changes have to
be differentiated from antemortem skull fractures.
Heat fractures: On postmortem, some charred bodies often
show skull fracture and intracranial hemorrhages. These
arise either due to violence before death or action of heat on
skull and brain or injury to head after death. Antemortem
fractures can be differentiated from postmortem fractures
by the presence of tissue reaction at the margin of the
fractured bone on microscopy, which would occur only if
the victim survived for at least an hour after injury. In case
victim dies in lesser time these changes will not be seen,
instead there will only be external signs of trauma.

Medicolegal Aspects of Burn Injuries
519
Heat fractures of skull have been described as two types
by Mortiz:
a. Increased intracranial pressure forcing contents of skull
outwards leading to an explosive fracture. These
fractures are seen along suture lines along with brain
matter exploding out in a circular pattern.
b. Drying and shrinkage of outer table leading to stellate
fractures and fragmentation of outer table which cracks
on handling, during postmortem, thus mimicking a
depressed fracture. However, in antemortem depressed
fractures, the outer table shows shelving along the edges
of the fracture.
CAUSES OF DEATH IN BURNS
The death in burn injuries may occur from:
1. Primary Shock/Primary Neurogenic Shock due to pain,
fear or inhibition
2. Secondary Shock due to loss of fluids is the most
common cause of death in first 24 hours.
3. Asphyxia or due to inhalation of smoke, carbon dioxide,
carbon monoxide gases.
4. Toxemia
5. Septicemia—when patient survives for some duration,
is the most common cause of death in the later period.
6. Acute Renal Failure with associated Bio-chemical
disturbances
7. Gastrointestinal Disturbances including Curling’s ulcers
8. Other complications, like tetanus, gangrene, amyloidosis
etc.
Spontaneous combustion of the human body cannot occur
as the human body is composed of seventy five percent of
its own weight of water.
Preternatural combustibility is rare. Inflammable gases
like Hydrogen sulfide, methane or Hydrogen are sometimes
formed in the alimentary tract due to bacterial fermentation
during digestive process. These gases are belched out from
the anal region and if a flame or flame producing object is
nearby the body, it may cause burns at the site. Similarly
during surgical procedures on large bowel or near that area,
while using electric cautery a mild explosion may occur
due to ignition of these gases. However, complete
combustion of body is impossible.
MEDICOLEGAL ASSESSMENT OF A
BURN VICTIM
A Medical Officer, Forensic expert, Forensic Pathologist or
any other doctor, who is authorized by the concerned State
Government by issuing a Gazette Notification under sub-
section 3 of Section 174 of the Criminal Procedure Code
can conduct Medicolegal autopsies. Basically, the following
facts are required to be determined in case of alleged deaths
due to burn injuries (1) Identification of the deceased—
age, sex, height (2) whether the burn injuries are antemortem
or postmortem in nature (3) what are the causes of death in
Table 35.1: Differentiating features of antemortem and postmortem burns
S.No.
Antemortem Burns
Postmortem Burns
1.
Evidence of vital reaction,
Present
Absent
line of redness.
2.
Vesicles
Fluids present containing albumins,
No fluid-only air present
chlorides
3.
Inflammation
Signs of inflammation, formation of
Absent
granulation tissues, pus and sloughs.
4.
Healing
Process of reparative changes present
Absent
5.
Enzymes
Increase in Enzymes
Nil
Estimation
Estimation
6.
Carboxy
Present
Absent
Hemoglobin in blood
7.
Carbon Soots in upper
Present
Absent
respiratory tracks
8.
Pugilistic
Present
Absent
Attitude/Boxer
Attitude
9.
Carbon soot
Present
Absent
in stomach due
to reflex swallowing

520
Principles and Practice of Burn Care
the deceased and (4) whether the burns are accidental,
suicidal or homicidal.
Identification
In majority of the cases of burns, bodies are already identified
prior to Medicolegal autopsy. But in cases of unidentified
bodies, detail examination of bones, jaws, pelvic bones,
status of teeth, obtaining finger prints from less damaged
hands or feet need to be done. In case of charred bodies,
marks of external wounds may be destroyed and
determination of even age and sex may be difficult. However,
even at 2000° F temperature all body parts are not destroyed.
Fragments of remaining long, short bones, pelvic bones,
teeth and jaw are carefully examined and X-rays are
evaluated. A detailed DNA finger printing further helps in
the identification.
Accidental Burns (Fig. 35.1)
Accidental deaths due to burns are generally reported at the
place of work like kitchen, factories, in burning houses or
buildings or shops, Cinema Halls (like in case of Uphaar
Picture Hall Tragedy, New Delhi), fire in some exhibition
(Shastri Park, Meerut, Uttar Pradesh), hotels (Siddhartha
Hotel now known as Vasant Continental Hotel, New Delhi)
and rarely in train compartments. Large number of deaths
in accidental burn injuries also occurs among aged persons,
infants, children, intoxicated or drugged persons, or persons
suffering from epilepsy or sudden syncope. Mainly the
women and men working in the kitchen, sustain burn injuries
due to leakage of cooking gas, bursting of kerosene oil stoves
(Fig. 35.3C) which is very common in India, falling of
kerosene oil lamps, burning candles during sleep, warming
during winter seasons from electric heaters or wooden fire
in remote areas of smaller cities and villages.
Suicidal Burns (Figs 35.2A to 35.3C)
Suicidal burns are relatively more common amongst Indian
women than males due to increasing tension in day-to-day
life with domestic problems, harassment by husband or his
family members, financial crisis, chronic illness, loss of life
of near and dear family member, depression or suicidal
tendencies. Careful evaluations of circumstances along with
detailed postmortem examination findings are evidence to
suggest suicidal burns. Self immolation is also a way of public
protest against some organization or Government policies, in
which the protestors, in public or other places which are in
public view pour kerosene oil on self and set the body on fire.
In suicidal burns usually some inflammable material like
kerosene oil, Petrol or Alcohol is used. The material is poured
Fig. 35.1: Case of accidental 100% antemortem burns showing singeing
of scalp hair, blackening of face, neck and upper chest due to clothes
catching fire following bursting of kerosene stove
Fig. 35.2B: Same case in pugilistic attitude with heat rupture in right
inguinal region. Intact bangles indicating no signs of struggle
Fig. 35.2A: 100% suicidal antemortem burns showing burned scalp
hair and charring of both upper arms

Medicolegal Aspects of Burn Injuries
521
Fig. 35.2C: Same case with pugilistic attitude, charring of skin of right
forearm, chest, lower thigh and knee with heat ruptures in left
lower leg
Fig. 35.2D: Same case with charring of skin of scalp and tuft of
scalp hair with area of redness over right hip
Fig. 35.3A: Suicidal burns showing burning of scalp hair and scalp
skin in the middle
Fig. 35.3B: Same case with singeing of scalp hair anteriorly indicating
suicide by pouring of kerosene oil on head also before igniting it
Fig. 35.3C: In the same case nonfunctional kerosene oil stove
allegedly blamed for accidental burns
Fig. 35.4A: Case of dowry burns with strangulation – Deceased
showing antemortem scalds on left index finger and dorsum of right
hand and hot metal antemortem burns on right thigh indicating torture
prior to strangulation

522
Principles and Practice of Burn Care
Fig. 35.4B: Same case with antemortem cigarette burns on lower lip
and right side of chest also indicating torture
Fig. 35.4C: Same case with deceased showing sign of
strangulation on neck
Fig. 35.5A: Typical antemortem homicidal burns with normal
hair and scalp
Fig. 35.5B: Same case with ink impression on right big toe suggestive
of recording of statement of the deceased prior to death
Fig. 35.5C: In the same case, visit of the scene of crime by the
autopsy surgeon who conducted the postmortem — Showing door
locked from inside
Fig. 35.6: Typical case of 100 % homicidal burns showing intact skin
as a white band on the face with surrounding burned skin indicating
that the patient was gagged before setting her on fire

Medicolegal Aspects of Burn Injuries
523
will help in evaluating the nature of burn injuries and cause
of death.
BIBLIOGRAPHY
1. Gordon I , Shapiro H A , Berson S D. Death from burns, Exposure
to high and low environmental temperatures and electrical injuries.
In I. Gordon HA, Shapiro SD, Berson (Eds) , Forensic Medicine –
A guide to principles (3rd ed) London: Churchill Livingstone
1988:138
2. Knight B. Forensic pathology (chapter 11). London: Edward Arnold,
1994, 292.
3. Mortiz AR. Personal communication quoted in I. Gordon HA,
Shapiro SD, Berson (eds), Forensic Medicine – A guide to principles
( 3rd ed) London: Churchill Livingstone 1988:149.
4. Polson CJ. Electrical injuries and lightening stroke. In CJ Polson,
DJ Gee, B. Knight (Eds), Essentials of forensic medicine. Oxford:
Pergamon Press, 1984, 282.
on the head and also other parts of body and then body is set
on fire producing characteristic features like burning/singeing
of scalp hairs, eyebrows and eyelashes, burning or charring
of scalp skin, ears, ear lobes or temple region.
Homicidal Burns (Figs 35.4A to 35.6)
Cases of homicidal burns are rare. Generally kerosene oil,
petrol, diesel, alcohol, hot metals or corrosive substances
have been used to inflict burn injuries. There is an
increasing trend of homicidal burns in India with the sole
intention of taking revenge or concealing the crime of
murder and accordingly bodies are burnt to destroy these
evidences. A detailed postmortem examination including
evaluation of circumstances, even a visit to scene of crime

524
Principles and Practice of Burn Care
Legal Requirements in
Managing Burn Patients
36
Atul Kumar Shah
Chapter
DISCLAIMER
Foregoing presentation is a personal view of the author, based on his
personal experience. Any future legal amendments may change these
views.
INTRODUCTION
Burn accidents usually take place due to failure to prevent.
This trauma has an element of suspicion of a crime added
to it in many cases. A treating physician has the responsibility
of informing such incidences to legal authority.
Police is constantly engaged in keeping law and order in
control. Society needs to support police in maintaining peace
and in reporting crime. Police actually has to classify any
mishap as crime and subsequently investigate the same.
For collecting information, police has to depend on various
channels; one of them naturally is the body of citizens.
Casualty doctors or treating physicians are duty bound to
inform the police when they are managing trauma victims.
Although this chapter deals with burn management and legal
requirements in treating a burn victim, same procedures
are equally applicable to other trauma, poisoning, drowning,
suicidal and homicidal victims.
INDIAN LEGAL SCENE
Indian Penal Code (IPC) enlists various body injuries. Code
of Criminal Procedures in section 39 asks every citizen to
inform police of any incidence which has harmed any human
being. For treating physician, informing police is, thus, an
extension of his duty as a citizen. To the best of knowledge
of the author, there is no requirement or compulsion specified
in Medical Council of India Act or Bombay Police Act and
the like.
SOCIAL CIVIC AND MORAL DUTY
Except as required under section 39 (section 40 for village
head, police Patel or a villager) of the criminal Procedure
Code, the need for informing the police in case of a
suspicious burn injury is social as well as moral rather than
legal. However, current sociolegal set up demands that police
should be informed, whenever a trauma or burn case of
nature as enlisted here, is received by a treating doctor.
SITUATIONS
All major burns and other major trauma victims when
received have to be notified to the police. Unexplained
severity, not matching with the history or circumstances,
needs reporting. Patients received after several days of burns
and without proper treatment, patients likely to succumb to
the injury, patients received dead and mass casualties need
to be notified to the police.
Usually when a patient succumbs to injuries, a certificate
of death is required to be issued. In this certificate the cause
of death has to be specified. When the treating doctor is not
certain about the cause of death, demand of a medicolegal
postmortem has to be made. Such a demand can only be
made through a police officer. When the police officer is
informed of such a request his team has to visit the site
where death has occurred. He carries out a report of the
condition and situation of the body, known as ‘panchnama’.
He also fills an inquest for a medicolegal postmortem. Later,
the body is handed over to this police officer, who takes it
to nearby health establishment equipped with postmortem
facilities. If the inquest has been filled in odd hours, the
body is shifted to a morgue for postmortem later or else the

Legal Requirements in Managing Burn Patients
525
body may be retained, at the request of the police officer, in
the same room until shifted for postmortem next day
morning. The police enter the scene and fill inquest without
wasting time; only if, they had been informed when the
patient first came for treatment or got admitted.
Sometimes, the patients come from distant places and
as per the police codes, the police officers of the area of
incidence are required to carry out legal procedures. It is
important to inform the nearby police immediately, so that
at the time of the death of the patient, the nearby police do
not waste time in procedural delays.
Similarly, in patients at extremes of age, extensive burns
and evident homicide or suicide, it is better to inform police,
as there is likelihood of death and subsequent postmortem.
All road traffic and industrial accidents are also to be reported
to police and are governed by the Motor Vehicle Act and the
Factories Act. It is the duty of the treating doctor, in his
capacity as a citizen or as a person with the information of
the mishap, to inform police.
HOW SOON TO INFORM?
Supreme Court of India in a judgment has clarified that
police activities can wait, the life of the victim is important
and hence the treatment must be instituted immediately. Some
judgments talk of ‘reasonable time’. Therefore, one can
conclude that as soon as the emergency care is over and
the patient is stabilized, the process of informing the police
may be started. Although it is not specified any where, we
must make efforts not to make any delay in informing the
police and this can be considered as within 4 to 6 hours or
in case of very specific situations within 12 hours. Delays
further than that may arouse suspicion in the mind of the
investigating officers and their co-operation may get
reduced.
WHOM TO INFORM?
This can be looked at from two different angles. In large
cities there are several police stations with area demarcations,
it may so happen that the burn incident may have occurred
in the jurisdiction of one police station and the treating
hospital may be in jurisdiction of another police station. If
the police station in which the area of accident falls is willing
to take the information on phone or if it is not far away and
written information can be sent without extra efforts, the
same may be done. Doctor can decide to inform the nearest
police station as an alternative.
The local police station may not be willing to take such
information if the area of incidence is different and many
times the approach of the local police station is variable
depending on the current officers and their superiors. In
case of such difficulties, in many places one can utilize
services of police control number 100. Here, telephonic
information can be given and it is one of the legal ways of
registering information. From Suburban areas also one can
call the district Police Control Room and the connecting
number is usually the same.
The burn victim comes from far off places, which may
fall in other districts and even other states. Treating doctor
or hospital may not invest time in trying to find out contacts
of the exact police station of the mishap area for passing on
the information. The nearest police station, under whose
jurisdiction the treating hospital falls, must, however, be
informed without fail. If, for some reasons, the nearest
police station shows inability to accept the information,
informing police control at 100 is a legal alternative. At many
places, police has announced e-mail addresses for accepting
such information.
MODE OF INFORMATION
Calling the police station on phone and giving brief particulars
of the victim as well as of the incidence is the accepted
way of intimation now at most of the places. Each police
station has one ‘on duty’ PSO (Police Station Officer) that
usually attends the phone and writes down the details. This
information is then passed on to the ‘on duty’ Investigating
Officer. The doctor is required to obtain the name of the
PSO and ask him as to what time of intimation he has entered
in his records. Later, the police station converts this
information into their procedural information and enters this
into a special register which they call ‘station diary’. On
shifting the information to station diary, a diary number or
FIR (First Information Report) number along with the date
and year is generated and it may be of help for subsequent
communication with the police.
Sometimes, the police insists on a written information,
in which case if it is feasible, a letter stating name, age,
gender, and address of the victim, address where mishap
occurred, time when mishap occurred, time when patient
arrived to current health establishment and whether police
has been informed by any other source(s) at any other health
establishment(s) treating the patient previously, must be sent
in duplicate so that proof of receipt can be obtained. As an
alternative, such a letter must be prepared in three copies

526
Principles and Practice of Burn Care
and two copies are handed over to a willing relative of the
patient, taking his signature on the third copy stating that he
has received a letter for informing the police. The relative
then goes to the police station and gets signature of the
PSO on the duplicate, which must then be received back in
the hospital. This exercise is necessary as it keeps a proof
with the hospital that a process of informing the police has
been initiated and it saves the hospital staff from running
around. The larger and designated government hospitals
have a satellite police post inside the hospital and the
information process is managed by specially appointed
casualty doctors.
In case of paucity of time and manpower, unwilling
relatives, unattended patients and when the nearby police
station or the police station of the mishap area have not
been reached by phone, call to police at control room number
100 would be sufficient. One must not forget to obtain the
name of the person who attends your call at police control
room and must register the time of such intimation in the
case paper at appropriate place.
Police Control Room later identifies the responsible police
station and transfers the information. Team from concerned
police station visits the hospital and takes note of the mishap
as well as the health status of the victim.
BURN INJURIES IN MARRIED FEMALE
When a married woman is brought with extensive burn
injuries, the police tend to treat this mishap as a dowry
problem unless proved otherwise with circumstanial
evidence. If the married life of the victim at time of mishap
is less than seven years, the police investigation becomes
stringent and under a senior officer of the rank not less
than a deputy commissioner. Death in such cases would be
governed by section 304B of Indian Penal Code that specifies
dowry deaths and can lead to imprisonment ranging from
seven years to life.
CRIMINAL NEGLIGENCE
In a recent Supreme Court Judgment, guideline has been
set up before applying section 304A against doctors. Rash
or negligent act leading to death can attract imprisonment
of up to two years and fine. However, the apex court has
asked the investigating officers to first obtain sanction from
senior government doctors to establish negligence in a
particular case before arresting a doctor.
SUMMARY
Informing police is the duty of every citizen and so also of
a doctor, when any mishap involving bodily injury is brought
to their notice. With usage of electronic media, it has become
less procedure oriented and less time consuming to inform
police. Physicians treating burns must make sure that legal
requirements have been properly met with.
BIBLIOGRAPHY
•
Indian Penal Code
•
Code of Criminal Procedures
•
Code of Ethics and Etiquette, Medical Council of India
Act

Burn Disfigurement and Physical Impairment Calculations
527
Burn Disfigurement and Physical
Impairment Calculations
37
Atul Kumar Shah
Chapter
INTRODUCTION
A burn victim is entitled to compensation for current and
future medical expenses, lost wages, disfigurement,
emotional sufferings, mental impairment and physical
disability. The concept of physical impairment has to evolve
amongst the burn specialists so that the award of disability
can become more meaningful. It must be realized that
disability is not purely a medical condition. Burn
disfigurement brings unwanted stress and breaks down self-
confidence and self-esteem. Burn injury victims also suffer
excruciating pain as their wounds heal. Burn patients undergo
painful skin grafting and other surgical procedures to repair
the damage done by the injuries. Burn survivors may endure
physical trauma, pain, body metabolism damage and changed
temperature sensitivity. After the physical scars begin to
heal, the emotional scars begin to surface. As a wild guess
based on the experience of the fellow burn specialist
colleagues, approximately one million burn injuries could
be occurring in our country per year. Approximately half of
these injuries are treated by medical professionals; about
one tenth of them are hospitalized. Of those hospitalized
many have major burns involving at least 25 % of their total
body surface. Between 20,000 and 25,000 of patients with
burns die and approximately half a million sustain substantial
or permanent disabilities resulting from their burn injury.
There must be very extensive and collective effort to bring
out the burn incidence data in the country and use of census
may also be taken to determine prevalence of disfigured
individuals.
Burn accidents may be caused by someone else’s
carelessness or failure to act. Many a times, it is a
combination of negligent act or a failure to act by one or
more persons or entities that causes an accident to occur.
Burn injuries can result from a variety of different activities
and sources. Whether at home or on the job, one can be
exposed to unknown dangers. The law requires that each
person owes every other person a duty to act as a reasonably
prudent person would act under the same or similar
circumstances. When a person or entity does not act
reasonably, then they have violated that duty and will be
held responsible for any injury or damage that results. This
duty is created from statutory laws or prior judgments of
the cases that have evolved over time.
As a trauma or burn specialist we must have some
understanding of the legalities of the award of disability by
various competent authorities. In India, currently we have
to depend mainly on the Workmen’s Compensation Act of
1923 and the Motor Vehicle Insurance Act to understand
the concept. Physical Impairment may translate into
limitations of functional capacity of any individual and these
limitations may be termed as ‘disability to sustain’ or
‘disability to earn livelihood’. The definitions from WHO
may make this point clear.
The chapter describes the difference between concepts
of physical impairment and disability and guidelines to
quantify permanent physical impairment.
Impairment and Disability
Impairment is permanent or transitory, psychological or
anatomical loss and/or abnormality. Paralysis, amputation,
diabetic retinopathy and even burn disfigurement or
contracture are physical impairments.

528
Principles and Practice of Burn Care
Functional Limitation is partial or total inability to perform
the activities necessary for motor, sensory or mental
functions within the range and manner of which the human
being is normally capable such as walking, lifting loads,
seeing, speaking, reading, writing, counting, taking interest
in and making contact with surroundings. Functional
limitations come from physical impairment and may last
for a short time, a long time, be permanent or reversible.
Idea is that, whenever possible, one must be able to quantify
these functional limitations. So these limitations are described
as regressive or progressive.
Disability is difficulty that exists in performing one or more
activities. These are the ‘Activities’ that in accordance with
the age, gender and normative social role of the person are
generally accepted as essential and basic components of
daily living such as self-care, social relations and economic
activity. Physical Impairment and functional limitations are
the causative factors for this disability. Also depending in
part on the duration of functional limitation, disability may
be permanent, long-term or short term. We may, however,
be dealing with Permanent Physical Impairment (PPI) and
Permanent Disability most of the time.
Recently, WHO has proposed revision of the earlier
definitions and has given new terminologies like ‘activity
limitation’ and ‘participation restriction’. Activity is the nature
and extent of functioning at the level of the person and may
be limited in nature, duration and quality. Participation is the
nature and extent of a person’s involvement in life situation
and the restriction is in relation to impairment of activities,
health conditions and contextual factors and participation
may be limited in nature, duration and quality.
According to Webster’s Dictionary, disability is defined
as:
1. “State of being disabled: Absence of competent physical,
intellectual, or moral power, fitness or the like; also an
instance of such lack”.
2. “Legal incapacity, incompetence, or disqualification”.
There are physical, social, psychological and vocational
effects to disability as well. A trauma specialist is, thus, not
equipped and qualified to determine disability of a person,
since disability is not purely a medical condition. Medical
doctors must, therefore, restrict to evaluating and certifying
physical impairment. In doing so the medical expert wishfully
thinks that the competent authority shall subsequently
consider the social, psychological and vocational aspects in
calculating the disability of the individual in question.
Unfortunately, currently the compensation authorities or the
courts of law have limited understanding to demarcate
between physical impairment and disability. Facial burns
may not be considered a disability at all, but how can such
a person ever become a marketing executive or a model or
a TV news reader! On the other hand, a paraplegic is
considered highly disabled, but he earns fortune by his vocal
performances or lecturing on stress management and also
qualifies for the concessions available to a disabled!
Under the Workmen’s Compensation Act, disability may
be divided into three periods.
Permanent disability shall apply to permanent damage or
to loss of use of some part of the body after the stage of
maximum improvement has been reached and the remaining
physical impairment is stationary; this physical impairment
shall then be termed as permanent physical impairment. There
is a question of time frame here, and one must allow at least
six months, if not more, before quantifying permanent
physical impairment.
Temporary disability can be total or partial.
Temporary total disability shall be the period during which
the individual is under treatment and totally physically
impaired for the time being.
Temporary partial disability shall be the period when the
physical impairment is partial to begin with or the person
has recovered from the total physical impairment.
Ultimate legal compensation may be awarded, usually,
for the permanent physical impairment of non-reversible
nature leading to permanent disability. A medical person,
thus, needs to evaluate permanent physical impairment and
may even be called in the court of law to testify as an expert
witness. Physical impairment certificates can be issued by
all medical graduates who are registered under the schedule
I of Medical Council of India Act 1956, and there is no need
for the medical graduate to be a specialist, as is some times
demanded by the lawyers. However, the court always
considers the specialization and the expertise of the certifying
doctor while relying on the assessment of physical
impairment certified by the doctor.
In the United States, the American Medical Association’s
Guides to the evaluation of permanent impairment is the
most commonly used source for assessing and rating an
individual’s permanent impairment. The fifth edition of the
“Guides” (Chicago, Ill: American Medical Association: 2000)
defines impairment as “the loss, loss of use, or derangement
of any body part, organ system or organ function”.
Impairments are defined at an organ system level with
objective measures such as lung or cardiac function.

Burn Disfigurement and Physical Impairment Calculations
529
Impairment ratings, based on medical consensus, were
designed to reflect the ability to perform basic activities of
daily living (e.g. personal hygiene, communication, standing,
walking, sleeping and social and recreational activities).
Typically, impairment ratings do not account for the effects
of accommodations (exceptions include the use of glasses
for assessing vision).
Impairment ratings in the “Guides” attempt to link
objective measures of organ function with the functional
tasks of performing activities of daily living, recognizing
that there is often insufficient scientific evidence to support
these ratings. Estimating work ability from an impairment
rating can be even more problematic. Although these activities
of daily livings are components of many workplace activities,
work is a complex and individualized activity. Thus, the
impairment ratings do not reflect an individual’s ability to
work, although they may be used to assess some
components of work ability. Disability is an alteration of an
individual’s capacity to meet personal, social, or occupational
demands because of an impairment or functional limitation.
The “Guides” does not directly address disability but talks
of work ability!
In India, apart from the Workmen’s Compensation Act,
the only other authentic documents available till date, to the
best of knowledge of the present author, are ‘The Manual
for Doctors to evaluate Permanent Physical Impairment1
and ‘Evaluation of Impairments, Disabilities in case of
Occupational and other Diseases and Accidents’.2 The
contents of the Manual for Doctors to evaluate Permanent
Physical Impairment are based on the experts’ group meeting
on Disability evaluation that was held in New Delhi in
September 1981 and also the National Seminar on Disability
Evaluation and Dissemination held in New Delhi in December
1981. The Manual is endorsed by Director General Health
Services (Govt of India), All India Institute of Medical
Sciences (New Delhi) and World Health Organization and
was published in March 1982.1 The evaluation criteria are
simplified and can be of immense help in issue of certificates
of Permanent Physical Impairment. Guidelines are given
here for evaluation of Permanent Physical Impairment in
Burns of Head and Neck (Table 37.1) and Burns of Trunk
and Genitalia (Table 37.2).
Guide lines for evaluation of physical impairment in burns
of upper extremity:
1. The estimation of permanent impairment depends upon
the measurement of functional impairment and is not
expression of a personal opinion.
2. The estimation and measurement should be made when
the clinical condition has reached the stage of maximum
improvement from the medical treatment. Normally this
time period is to be decided by the medical doctor who
is evaluating the case for issuing the Permanent Physical
Impairment Certificate as per standard format of the
certificate.
3. The upper limb is divided into two component parts;
the arm component and the hand component.
4. Measurement of loss of function of arm component
consists of measuring the loss of motion, muscle strength
and coordinated activities.
5. Measurement of loss of function of hand component
consists of determining the prehension, sensation and
strength. For estimation of prehension; opposition, lateral
pinch, cylindrical grasp, spherical grasp and hook grasp
have to be assessed as shown in hand component section
of Assessment Performa for upper extremity.
6. The impairment of the entire extremity depends on the
combination of the functional impairments of both
components.
For extremities, one can take help of The Manual for
Doctors to evaluate Permanent Physical Impairment or the
recently published guidelines from Ministry of Social Justice.
()
Detailed format for extremity evaluation can be obtained
from
In Workmen’s Compensation Act, the reward is based
on the wages as well as the involved parts and a brief
summary of the currently awarded compensation is given
here in Table 37.3.
Plight of a Burn Survivor
When any earning member of the family sustains major
burn injury, the entire family receives the crunch. Unlike
other trauma or disease, the management of burns is
prolonged, painful and costly. The economic resources of
the family get exhausted with the extent of treatment.
Industrial burn accident victims are no exception. The burn
survivor has to face challenges constantly even after the
initial assault is over.
1. Physical and emotional trauma
2. An injury that leaves one in pain
3. Disfigurement
4. Organ damage
5. Metabolic and biochemical damage
6. Sensitivity to temperature change

530
Principles and Practice of Burn Care
Table 37 .1: Guide lines for evaluation of physical impairment in burns of head and neck. Ten point formula for evaluating post burn
disfigurement of head and neck. Total 100 points and eight equitable components
Component
Equitable Points
Split up Points
1.
Scalp and Vault (10)
10 (Includes Forehead)
a.
Scalp(Disfigurement alone)
2.5
b.
Scalp and Skull Bone Involvement
10
2.
Eye Brows (10)
5 each, 10 for both
a.
Part of One
2.5
b.
Total Loss of One
5
3.
Eye Lids (20)
6 for Upper, 4 for Lower
a.
Upper - Skin Disfigurement alone
Per Side
1.5
b.
Upper - Deformity or Full Thickness Loss
Per Side
6
c.
Lower - Skin Disfigurement alone
Per Side
1
d.
Lowerer - Deformity or Full Thickness Loss
Per Side
4
4.
Pinna (20)
10 per side
a.
Anterior or Posterior - Skin Disfigurement Alone
Per Side
2.5
b.
Deformity due to full thickness involvement of skin and cartilage without
Per Side
7.5
obliteration of meatus
c.
Deformity due to full thickness involvement of skin and cartilage with
10
obliteration of meatus
5.
Nose (10)
10
a.
Skin Cover Disfigurement alone
2.5
b.
Deformity due to full thickness involvement with both Nares Patent
7.5
c.
Full thickness deformity with one nare obliterated (7.5 +1.25)
8.75
d.
Full thickness deformity with both nares obliterated
10
6.
Cheek and Lateral Area of Face(10)
5 Each
a.
Skin Cover Disfigurement alone
Per Side
1.25
b.
Deformity or Full Thickness Loss
Per Side
5
7.
Lips - Upper or Lower (10)
5 Each
a.
Lips - Upper or Lower skin cover disfigurement
Per Side
1.25
b.
Lips - Upper or Lower skin cover disfigurement crossing midline
2.5
c.
Deformity or full thickness loss of one lip alone
5
d.
Deformity due to involvement of both lips leading to contracture of oral opening
10
8.
Neck (10)
10
a.
Skin Cover Disfigurement alone
Per Side
2.5
b.
Deformity due to involvement of skin, muscles or deeper tissues
10
Table 37.2: Guidelines for evaluation of physical impairment in burns of trunk and genitalia
1.
Front of Trunk and Abdome excluding Breasts
Female
10
Male
5
2.
Breast each Side
Female
20
Male
5
total or as per detail below
a.
Only Skin Cover disfigurement each side
Female
5
Male
1.25
b.
Involvement of Skin, Areola and Nipple and/or
Female
15
Male
5
Deformity resulting in loss of function - per side
c.
Involvement of Skin, Areola, Nipple and
Female
20
Male
5
parenchyma and / or Deformity resulting in loss
of function- per side
3.
Total Back
Female
5
Male
10
4.
Groins - each side
Female
5
Male
5
5.
Buttocks - each side
Female
2.5
Male
2.5
6.
Genitalia total
Female
30
Male
60
a.
Skin loss resulting in mild deformity
Female
7.5
Male
15
b.
Severe contracture of orifices or sloughing
Female
30
Male
60
of urethra or severe deformity of penis

Burn Disfigurement and Physical Impairment Calculations
531
Legal Rights of Burn Survivors to
Compensation
Highly dependant upon the prevailing legal and social support,
the following compensation can be claimed by the burn
victim depending on the cause of the burn injury.
Compensatory damages “compensate” the injured person
for various kinds of losses or damages and include - current
medical expenses, lost wages, anticipated future medical
expenses, anticipated future loss of wages, mental or
emotional pain and suffering (past and anticipated in the
future), disfigurement and any physical or mental impairment
or disability.
I. Payment for treatment—Past and future
1. Hospitalization
2. Surgical procedures
3. Ongoing medical care
4. Counseling
5. Scar revisions—Cosmetic surgery
6. Physical therapy
7. Occupational therapy
II. Compensation for loss of income—past and future
III. Vocational Rehabilitation (job retraining)
IV. Compensation for pain and suffering—Burn survivors
may be entitled to compensation for the pain and
suffering that they have endured and may continue to
endure as a result of their injury
V. Loss of Consortium—This is a novel concept for Indian
Judiciary and may soon find its place in the case laws.
The Spouses of a burn survivor may be entitled to
compensation when an injury is so severe that it
interferes with the injured party’s spousal relations.
The affected family member may suffer a very real
detriment. Many courts recognize the right of the
injured party’s spouse to recover in an appropriate case
for a loss of support, services, love, companionship,
society, affections, sexual relations and solace in the
form of a loss of consortium action. Loss of
consortium is a claim separate from the injury victim’s
claim. It is unique to the injured party’s spouse and is
compensable by a separate damages recovery.
Indian Legal Enforcements
Burn survivors with untreatable contractures, keloids,
grafted area, disfigurement and the like can be qualified to
receive state help. Burn and trauma experts need to put up
united front in making these benefits available to burn
survivors. The enactment of the “Persons with Disabilities
(Equal Opportunity, Protection of Rights and Full
Participation) Act, 1995 (referred to as Persons with
Disabilities Act), is a signal achievement of the Indian
disability movement. Preamble to this Act clearly delineates
its objectives of promoting and ensuring equality and full
participation of persons with disability. The Act aims to
protect and promote economic and social rights of people
with disability. In Section 2(t), a person with disability means
‘ a person suffering from not less than forty percent of any
disability as certified by a medical authority’. The disabilities
that have been listed in section 2 include blindness, low
vision, hearing impairment, loco- motor disability or cerebral
palsy, mental retardation, mental illness and persons cured
of leprosy. In addition, autism and multiple disabilities have
been covered under the “National Trust for Welfare of
Persons with Autism, Cerebral Palsy, Mental Retardation
and Multiple Disabilities Act, 1999”.
Table 37.3: Indicative Compensation payable currently under the Workmen‘s Compensation Amendment Act (46 of 2000)
Instance
Minimum Compensation
a.
Where Death result from Injury
Rs. 80,000
b.
For Permanent Total Disability
Rs. 90,000
c.
For Permanent Partal Diablement
As per % of loss of earning capacity. It varies from 1 % to 90 %
d.
Temporary Disablement
An amount equal to 50 % of monthly wages subject to maximum Rs. 1000. For up to 3 days
disablement, no compensation is payable. But if it is more than 3 days but less than 28 days,
then 50 % of the balance days wages are payable. If it is more than 28 days, then the 3 days are
not deducted.
After the 2000 amendment, the maximum liability under the act for workman is limited to a monthly wage of Rs. 4000. In such cases the
compensation based on actual last monthly wage is as follows.
a.
Where Death result from Injury
An amount equal to 50 % of monthly wages of the deceased workman multiplied by the relevant
age factor or Rs. 80,000 - whichever is more.
b.
For Permanent Total Disability
An amount equal to 60 % of monthly wages of the deceased workman multiplied by the relevant
age factor or Rs. 90,000 - whichever is more.

532
Principles and Practice of Burn Care
Prevention of Disability
The law in its present form only exemplifies a narrow
understanding of the right to health with emphasis on
prevention, cure, improvement or elimination of disability,
which in any case are conditions that generally exist before
the onset of disability and therefore, have no logical
connections to the rights of those who are disabled. For
example, Section 25 of the Persons with Disabilities Act,
1995, states as follows: “Within the limits of their economic
capacity and development, the appropriate Governments
and the local authorities with a view to preventing the
occurrence of Disabilities, shall, (a) undertake or cause to
be undertaken surveys, investigations and research
concerning the cause of occurrence of Disabilities; (b)
promote various methods of preventing disabilities; (c)
screen all the children at least once in a year for the purpose
of identifying ‘at-risk’ cases; (d) provide facilities for training
to the staff at the Primary Health Centers; (e) sponsor or
cause to be sponsored awareness campaigns and disseminate
or cause to be disseminated information for general hygiene,
health and sanitation; (f) take measure for prenatal, perinatal
and postnatal care of mother and child; (g) educate the public
through the pre-school primary health centers, village level
workers and “anganwadi” workers; and (h) create awareness
amongst the masses through television, radio and other mass
media on the causes of disabilities and the preventive measures
to be adopted.
As certain groups among the disabled are more
vulnerable than others, a special enactment for the protection
of such persons, their property and well-being was felt
necessary. The enactment of the National Trust for Welfare
of Persons with Autism, Cerebral Palsy, Mental Retardation
and Multiple Disabilities Act 1999 (referred to as the National
Trust Act) aims to fulfill a common demand of families
seeking reliable arrangement for their severely disabled
wards. The specific objectives of the Act are:
1. To enable and empower persons with disabilities to live
as independently and as fully as possible within and as
close to the community to which they belong;
2. To promote measures for the care and protection of
persons with disability in the event of death of their
parent or guardian; and
3. To extend support to registered organizations to provide
need based services during the period of crisis in the
family of disabled covered under this act.
The National Trust Act mandates the creation of a local
level committee (LLC) comprising District Magistrate along
with one representative from a registered organization and
one person with a disability.
The Rehabilitation Council of India Act, 1992
The Rehabilitation Council of India was set up by the
Government of India in 1986 initially as a society to regulate
and standardize training policies and programmers in the
field of rehabilitation of persons with disabilities. The urgent
need for minimum standards was felt as the majority of
persons engaged in education, vocational training and
counseling of persons with disabilities were not professionally
qualified. Poor academic and training standards adversely
affect the chances of disabled succeeding in the world of
work. Therefore, an Act of parliament in 1992 enhanced
the status of the council to a statutory body with following
aims:
1. To standardize training courses for professionals dealing
with people with disabilities;
2. To prescribe minimum standards of education and
training for various categories of professionals dealing
with people with disabilities;
3. To regulate these standards in all training institutions
uniformly throughout the country;
4. To promote research in rehabilitation and special
education; and
5. To maintain Central Rehabilitation Register for
registration of professionals.
The Rehabilitation Council of India (RCI) regulates
training standards for sixteen categories of rehabilitation
workers. The Council is pro-actively promoting training
and research initiatives utilizing experience of specialized as
well as mainstream academic institutions.
Ministry of Social Justice and Empowerment had
amended section 47 of the Persons With Disability (PWD)
Act regarding non-invalidation of the government servant
who has been permanently incapacitated on account of
mental or physical disability vide order 6/17/2002-SCS/1925
and states that no establishment shall dispense with or reduce
in rank an employee who acquires a disability during his
service and the employee who has acquired disability, if not
suitable for the post he was holding, could be shifted to
some other post with the same pay scale and service benefits.
In case it is not possible to adjust him against any post, he
may be kept on supernumerary post until a suitable post is
available or he attains the age of superannuation, whichever
is earlier. No promotion shall be denied to a person merely
on the ground of his disability.

Burn Disfigurement and Physical Impairment Calculations
533
According to the persons with Disabilities Act rules,
Ministry of Social Justice and Empowerment issued a gazette
notification on June, 1, 2001. Here guidelines for evaluation
of following disability and process of certification are
outlined (i) visual disability, (ii) loco-motor / orthopedic
disability (iii) speech and hearing disability, (iv) mental
retardation and (v) multiple disabilities. Medical Board duly
constituted by the Central and State Governments can only
issue disability certificate. The State Government can
constitute a medical board consisting of at least three
members out of which at least one shall be a specialist in
the particular field, as the case may be. The Director General
of Health Services, Ministry of Health and Family Welfare,
Nirman Bhawan, New Delhi will be the final authority,
should there arise any controversy/doubt regarding the
interpretation of the definitions/classifications/evaluation
tests and the like.
SUMMARY
Quantifying the Permanent Physical Impairment and issuing
authenticated certificate for the same has been facing cross
questions from the advocates. There is limited understanding
about difference between physical impairment and disability
amongst medical and non-medical fraternity. Medical
personnel are empowered by the MCI act to issue certificate
of Permanent Physical Impairment based on the guidelines
prevailing in the country at present. It then becomes the
duty of the Law or compensation authorities to calculate
loss of earning capacity of the person. Guidelines for
calculating physical impairment in burns of head and neck,
face, trunk and genitalia are based on the area and depth of
involvement and calculation can be so based easily in arriving
at the percentage of permanent physical impairment of a
particular anatomical component of the body. There are
several efforts at both the national and international level to
help and support disabled persons and burn survivors would
qualify for several of these services.
REFERENCES
1. The Manual for Doctors to evaluate Permanent Physical
Impairment- DGHS, March 1982.
2. Evaluation of Impairments, Disabilities in case of Occupational
and other Diseases and Accidents-Society for Participatory Research
in India, December 1996.
BIBLIOGRAPHY
1. American Medical Association’s Guides to the evaluation of
permanent impairment-American Medical Association: 2000
Chicago, Ill.
2. The Workmen’s Compensation Act 8 of 1923 Full Text available
at tfnm=192308
3. The Workmen’s Compensation (Amendment) Act, 2000 ACT NO.
46 OF 2000. Full Text available at
fullact1.asp?tfnm=200046
4. Guidelines on Disability – Ministry of Social Justice available at
Pwd Act, 1995: The Persons With
Disabilities (Equal Opportunities, Protection of Rights and Full
Participation) Act, 1995, Full Text available - http://

(Trang không có chữ)

Organization of a Burn Unit
535