Modern Burn Surgery: Operative Decisions From Acute Excision to Long-Term Reconstruction

Burn injury remains a major global surgical and public health problem, causing substantial mortality, disability, economic loss, and long-term functional impairment, with a disproportionate burden in low- and middle-income countries. This narrative evidence-based review critically examines contemporary burn surgery across the entire burn care pathway, from initial assessment and operative timing to excision, wound coverage, reconstruction, scar surgery, and emerging technologies, with emphasis on evidence quality and ongoing controversies. A comprehensive search of PubMed, EMBASE, and the Cochrane Library was conducted for English-language publications from 2000 to 2026 using search terms related to burn surgery, burn wound management, excision, skin grafting, dermal substitutes, reconstruction, and scar management. Priority was given to international guidelines, systematic reviews, meta-analyses, randomized controlled trials, cohort studies, and landmark surgical publications. Current evidence supports early specialist assessment, timely excision of clearly deep burns, and definitive wound closure with autologous skin grafting or selected adjunctive reconstructive techniques as the cornerstones of modern burn surgery. However, uncertainty persists regarding the optimal timing of excision, the comparative effectiveness of debridement techniques, and the indications for dermal substitutes and regenerative therapies. Increasing evidence also supports a continuum-based reconstructive approach that integrates scar prevention and functional restoration from the acute phase of burn care. Overall, burn surgery has evolved from simple wound closure to biologically informed, function-preserving reconstruction across the entire burn care pathway. Although significant advances have been achieved, further high-quality comparative research is required to define optimal surgical strategies and facilitate the safe integration of emerging regenerative technologies into routine clinical practice.