Understanding burns and the role of skin grafts

Burn injuries are an unfortunate reality in South Africa, with more than 1.5 million South Africans experiencing burns each year. 

While the cause of the burn may range from open flames to accidental exposure to hot liquids, the healing process for the skin can be as complicated as the organ itself.

Dr Rachel Moore, Chief Medical Officer of Mediclinic Southern Africa and previously a  specialist surgeon in the Adult and Paediatric Burns Units at Chris Hani Baragwanath Academic Hospital, is a qualified instructor for the Emergency Management of Severe Burns course administered by the South African Burns Society and passionate about burns care. She offers insights into the essential role that skin donation and skin grafts play in treating burns.

Facing the facts about burns and skin donation:

• Thousands of South Africans suffer life-threatening burns every year, many of whom are children.
• Skin donation is lifesaving and can make a profound difference in the speed and quality of overall healing (not only the burn wounds).
• Only the top layer of skin is removed during donation. The Organ Donation Foundation describes this as “when skin is donated, only a very thin layer (similar to tissue paper) is removed and the area from which it is retrieved looks like a light graze.”

Skin graft’s role in healing

When a portion of skin is damaged, affecting the deep layers, the body cannot repair itself. Doctors are able to take healthy skin from another part of the body that is not burned and place it over the burned area.

The process goes beyond covering the wound to allow it to heal. A burn wound causes a massive inflammatory response at the wound site, which then negatively affects the body to a greater or lesser extent, depending on the size of the burn. The larger the burn wound, the greater the response.

Skin grafts may differ according to the thickness of the skin graft. Most commonly, skin grafts are only part of the skin thickness (split skin grafts), with the entire thickness of the skin (full thickness skin grafts) used in specific circumstances and areas of the body.

Unlike many transplant patients, the choice to do a graft is driven by needs of the patient rather than being good candidates, and the timing of when the grafting is done. In patients who need skin grafts it is important that the burn wound itself is optimised before grafting (e.g. removing dead skin, ensuring no wound infection), and that the patients themselves are in the best possible condition (e.g. nutrition optimised, no other active infection).

The role of skin donation

Dr Moore explains, “The skin is an organ (the largest in the body in fact!) and thus can be donated after death along with other organs like kidneys, liver, and lungs. Donor skin is lifesaving in patients who have massive burn injuries as it provides cover for the wound, which limits massive fluid loss from the burn area, protects the wound against infection, decreases pain, and dampens the life-threatening inflammatory response.”

In considering the comparison between donated skin’s effective to help patients compared to other treatment options, she emphasises that donor skin is by far and away the best option to cover burn wounds as it is a so-called “biological dressing” which makes the body believe that the wound is covered with its own skin i.e. healing itself.

While donor skin is used as a temporary covering because the body will recognise it as coming from another person and will eventually reject it, it plays a vital role in protecting the wound and supporting patient stabilisation and wound healing in the short term, until it can be replaced with the patient’s own skin for permanent healing.

Skin can be harvested from accessible, suitable areas of the donor’s body. It is initially stored in a fluid for transport to a tissue bank, where it is processed and placed in a solution for long-term storage.

Healing

A split-skin graft usually heals within 2 to 3 weeks. The area where the skin is placed (graft site) begins to attach (“take”) within the first week, while the area from which the skin was taken (donor site) typically heals within 10 to 14 days. Although the wound closes within weeks, full recovery and skin strengthening continue over several months.

In considering the care needed for such patients, Dr Moore explains that the graft site needs to remain covered and experience as little movement across it as possible. It remains closed for three to five days before first exposure, with regular dressing changes thereafter. Good pain management is essential, along with ongoing medical care of the patient.

The value of donation

According to Dr Moore, a skin graft converts an open wound that is excruciatingly painful, loses fluid, has ongoing inflammation, and is at high risk of becoming infected, into a healing wound. In patients with extensive burn wounds, skin grafts also improve overall healing.  

While a wound that heals without a graft (secondary intention) takes longer to heal, it often has more pronounced scarring due to a more disorganised form of wound healing. This also tends to lead to greater restriction of movement due to contractures. Skin grafts themselves do cause scarring, but in a more controlled fashion. They may only partially “take” and thus have areas of more disorganised scarring.

But the good news is that burn victims have hope for the future, as advancements in skin grafts are ongoing. Dr Moore is excited about this field and explains that developments include bioengineered skin substitutes, stem-cell therapies, spray-on skin cells, technology to cover large wound areas using very small amounts of donor skin, stem cell therapies, advanced synthetic and biosynthetic dressings, immunomodulation, and a focus on holistic recovery (i.e. functional outcomes, scar reduction, psychosocial rehabilitation) rather than simply survival.

How do you become a skin (or organ) donor?

• Register with the Organ Donation Foundation Home | Organ Donation South Africa OR
• Register with a tissue bank. Become a Donor with Vitanova: Save Lives Today OR Understanding Donation | Centre for Tissue Engineering

Important practical points in South Africa:

• Your family (next of kin) must give consent at the time of death [vitanova.org.za]
• Registration alone is not legally binding without family agreement
• Have the conversation with your family so that they clearly understand that you want to donate skin and other tissues; document your wishes.

Myths debunked around donation:

• MYTH: There cannot be an open casket funeral if skin was donated because the body will be disfigured.
  • Tissue recovery is done with respect and reconstructive techniques
  • Any impact is not visible once the body is prepared and clothed
  • Families can still have an open-casket funeral if desired
• MYTH: It is a “nice-to-have” addition to donating other organs.
  • Donor skin is potentially lifesaving, often in children
• MYTH: Only young, perfectly healthy people can donate skin or tissue.
  • Age alone does not exclude donors, many medical conditions do not prevent donation, each donor is assessed individually, many people who assume they are not eligible to donate are actually potential donors.
• MYTH: Skin or tissue donation conflicts with religious / cultural beliefs
  • Many faiths / religions view donation as act / expression of selflessness and compassion
  • Donation can be seen as an expression of ubuntu and altruism
• MYTH: Burial or cremation will be delayed or disrupted.
  • Donation is coordinated so that funeral arrangements can proceed as normal
  • The body is treated with care, dignity, and respect
• MYTH: Rich or influential people get priority for donated tissue.
  • Allocation is based on medical need, compatibility, not wealth or status
• MYTH: As long as I am registered as an organ / tissue donor, donation is guaranteed after my death.
  • Family consent at time of death is required in South Africa, so have the conversation with your family.