Journal of Surgical Research 91, 106 –110 (2000)

doi:10.1006/jsre.2000.5909, available online at http://www.idealibrary.com on

Percentage of Burned Body Surface Area Determination

in Obese and Nonobese Patients
Edward H. Livingston, M.D., and Scott Lee, B.S.
VAMC Greater Los Angeles Health Care System and the UCLA School of Medicine Bariatric Surgery Program,
Los Angeles, California 90099-5786

Presented at the Annual Meeting of the Association for Academic Surgery, Philadelphia, Pennsylvania, November 18 –20, 1999

INTRODUCTION
Background. The measurement of burn surface area
is important during the initial management of burn
patients for estimating fluid requirements and deter- Fluid resuscitation for burn patients must be care-
mining hospital admission criteria. The “rule of nines” fully administered during the first few h following a
is commonly used for this purpose. However, the pro- major burn. Inadequate fluids will result in continued
portional contribution of various major body seg- shock with worsening of end organ damage. Excessive
ments to the total body surface area changes with fluid administration will place the patient at risk for
obesity. Similarly infants have very large heads, alter- the development of pulmonary edema. Because it is
ing the overall contribution of other body segments to impractical to measure the volume status with central
the total body surface area. venous catheters early during burn resuscitation, the
Methods. Detailed body surface area measurements amount of fluids given is estimated. All at the com-
were made in 47 patients: 18 were of normal weight, 6 monly used formulas rely on an estimation of the per-
were moderately obese, and 23 were seriously obese. centage of burned body surface area. Fluid losses
Published tables of similar measurements for infants across the burned surface area may be substantial and
were reviewed to determine how the rule of nines need to be replaced.
applied to these populations. The contribution of the The formula most commonly used to estimate burn is
major body segments to the overall body surface area the rule of nines. The major body segments are consid-
was calculated and compared to estimates that would ered multiples of nine: Each arm is considered 9% of
be derived for these segments from the rule of nines. the total body surface area (BSA), each leg 18%, the
Results. The rule of nines provides reasonable esti- anterior and posterior trunk each represent 18% (with
mates of body surface area for patients ranging from the total trunk contributing 36%), the head 9%, and the
10 to 80 kg. For obese patients weighing more than 80 perineal area 1% [1, 2]. This formulation applies to the
kg a rule of fives is proposed: 5% body surface area for “average” patient. How the rule might apply to obese
each arm, 5 ⴛ 4 or 20% for each leg, 10 ⴛ 5 or 50% for patients is not known. The incidence of obesity is rap-
the trunk, and 2% for the head. For infants weighing idly increasing [3], being as high as 50% in some pop-
less than 10 kg a rule of eights applies: 8% for each ulations. In children the propensity to get burned is
arm, 8 ⴛ 2 or 16% for each leg, 8 ⴛ 4 or 32% for the higher with obesity [4]. Young obese patients have a
trunk, and 20% for the head. very high mortality due in part to trauma [5]. Obese
Conclusion. Various body parts differentially contrib-
patients often have underlying end organ damage from
ute to the total body surface area. Because these rela-
fatty infiltration of various organs or hypertension [6],
tionships remain relatively constant throughout
leaving them particularly susceptible to adverse effects
growth, the rule of nines provides reasonable estimates
of inappropriately administered resuscitative fluids.
for the determination of burned body surface area for
Despite the need to optimize fluid management for
most children and adults. These relationships break
down for infants and obese adults and the proposed
obese individuals the rule of nines has not been tested
modifications to the rule of nines provide better esti-
for these patients. We hypothesized that fat accumu-
mates of surface area for these groups. © 2000 Academic Press lation in obesity would result in an altered body sur-
face area distribution for obese individuals relative to

0022-4804/00 $35.00 106

Copyright © 2000 by Academic Press
All rights of reproduction in any form reserved.
 LIVINGSTON AND LEE: MEASUREMENT OF BURN SURFACE AREA 107

TABLE 1
Measurements and Constants for Linear Formula
(Measurements Taken with Subject Lying on a Flat
Surface)

Head: AB*0.308
A—Around vertex and point of chin
B—Coronal circumference around occiput and forehead, just
above eyebrows
Arms: F(G ⫹ H ⫹ I)*0.611
F—Tip of acromial process to lower border of radius, measured
with forearm extended
G—Circumference at level of upper border of axilla
H—Largest circumference of forearm (just below elbow)
I—Smallest circumference of forearm (just above head of ulna)
Hands: JK*2.22
J—Lower posterior border of radius to tip of second finger
K—Circumference of open hand at the metacarpophalangeal
joints
Trunk (including neck and external genitals in the male, breasts
in female): L(M ⫹ N)*0.703
L—Suprasternal notch to upper border of pubes
M—Circumference of abdomen at level of umbilicus
N—Circumference of thorax at level of nipples in the male and
just above breasts in the female
Thighs: O(P ⫹ Q)*0.508
O—Superior border of great trochanter to the lower border of
the patella
P—Circumference of thigh just below the level of perineum
Q—Circumference of hips and buttocks at the level of the
great trochanters
FIG. 1. Measurements used for the “linear formula.” These are
Or thighs: W(P ⫹ Q)*0.552 the locations for the measurements described in Table 1.
W—Upper border of pubes to lower border patella (measured
with legs straight and feet pointed anteroposteriorly)
P—As above normal-size ones. Therefore, we measured the BSA in a
Q—As above series of patients to determine what formula would be
Legs: RS*1.40 appropriate for estimating fluid resuscitation in
R—From sole of foot to lower border of patella burned obese patients.
S—Circumference at level of lower border of patella
Feet: T(U ⫹ V)*1.04
T—Length of foot including great toe
METHODS
U—Circumference of foot at base of little toe
V—Smallest circumference of ankle (just above malleoli) Patients and measurements. Consecutive patients seen in medi-
cine and surgery clinics were examined. Patients were selected to

TABLE 2
2
Surface Area in cm for the Various Body Segments

BMI ⬍ 29 BMI ⫽ 30–39 BMI ⬎ 40

Body segment Surface area (m 2) % Total BSA Surface area (m 2) % Total BSA Surface area (m 2) % Total BSA

Head 0.0534 ⫾ 0.0012 2.7 0.0536 ⫾ 0.0011 2.5 0.0469 ⫾ 0.0011 1.5
Arm 0.2477 ⫾ 0.0090 12.6 0.2504 ⫾ 0.0118 11.8 0.3196 ⫾ 0.0160 10.4
Hand 0.0785 ⫾ 0.0033 4.0 0.0780 ⫾ 0.0036 3.7 0.0805 ⫾ 0.0029 2.6
Trunk 0.7530 ⫾ 0.0337 38.3 0.8777 ⫾ 0.0432 41.4 1.468 ⫾ 0.0651 47.8
Thigh 0.4428 ⫾ 0.0115 22.5 0.4521 ⫾ 0.0160 21.3 0.6235 ⫾ 0.0226 20.3
Leg 0.2385 ⫾ 0.0073 12.1 0.2475 ⫾ 0.0071 11.7 0.3727 ⫾ 0.0174 12.1
Foot 0.1520 ⫾ 0.0072 7.7 0.1625 ⫾ 0.0037 7.7 0.1596 ⫾ 0.0053 5.2
Total 1.966 ⫾ 0.1425 100 2.175 ⫾ 0.1640 100 3.071 ⫾ 0.2248 100

Note. Data are presented as the mean ⫾ SEM.

108 JOURNAL OF SURGICAL RESEARCH: VOL. 91, NO. 2, JUNE 15, 2000

TABLE 3
Rule of Nines and Resultant Error When Used Relative to Actual Measurements
for Major Body Segments Measured in This Study

Rule of nines (%) Normal (%) Error Overweight (%) Error Obese (%) Error

n 18 6 23
BMI 25.0 ⫾ 0.8 32.6 ⫾ 1.1 56.3 ⫾ 2.6
Head 9 3 ⫹6 3 ⫹6 2 ⫹7
Arms 18 17 ⫹1 16 ⫹2 13 ⫹5
Trunk 36 38 ⫺2 41 ⫺5 48 ⫺12
Legs 36 42 ⫺6 41 ⫺5 38 ⫺2

exclude those with diagnoses that affect body composition such as Table 3 compares rule of nines estimates to actual
cancer. Patients presenting for morbid obesity surgery evaluation measurements of surface areas in individuals of nor-
were also included. All patients were weighed on a calibrated scale.
Their height, lengths, and circumferences of body segments were mal size and in obese individuals. With increasing
measured as given Fig. 1 and Table 1 to the nearest millimeter. The obesity there is progressive underestimation of the
linear method for converting these measurements to total BSA was trunk and leg surface area with overestimation of the
used [7]. With this technique surface area was determined by mul- arm and head surface area. This relates primarily to
tiplying the circumference of a body segment by its length and a greater fat accumulation in the trunk and legs than in
factor correcting for shape. The various surface areas were summed
to determine the total BSA. Body mass index (BMI) was determined the arms with obesity. Table 4 presents a comparison
by dividing the weight by the square of the height in meters. of the various rules to actual surface area measure-
Rule formulation based on previously published data. Data pub- ments for the three major categories of body types that
lished by Boyd [8] were used to construct tables comparing the the rules apply to.
relative contribution to body surface area of the major body seg-
ments. This facilitated comparison of measurements we obtained
from adults to the extensive pediatric data collated by Boyd. DISCUSSION

RESULTS Estimation of total burn surface area (TBSA) is im-

portant for estimating outcomes for burned patients,
A total of 47 patients were measured. Their weights calculating nutritional requirements, and determining
ranged from 51.3 to 248.6 kg. Heights ranged from 152 fluid requirements [9]. Because of the importance of
to 182 cm with a mean of 167 ⫾ 1.4. The lowest BMI TBSA in the management of burned patients estimates
was 18.3 and the highest 91.3. Eighteen patients had should be as accurate as possible. Extensive studies
BMIs less than 29 (mean BMI ⫽ 24.9 ⫾ 0.8), 6 ranged have been performed which measure the surface area
from 30 to 39 (mean BMI ⫽ 32.6 ⫾ 2.0), and 23 had of various major body segments [8, 10]. Infants have a
BMIs exceeding 40 (mean BMI ⫽ 56.3 ⫾ 2.6). Surface disproportionately large head surface area compared to
areas for the various body segments and their contri- children or adults. However, with growth, the propor-
bution to the total percentage of BSA are presented in tions the various major body segments contribute to
Table 2. body surface area are remarkably constant [8]. Thus,

TABLE 4
Actual Surface Area Measurements Compared to the Proposed Rules

Weight (kg): ⬍10 kg 10–80 kg ⬎80 kb

(BMI ⬍18) (BMI 18–30) (BMI ⬎30)

Actual Rule of eights Error Actual Rule of nines Error Actual Rule of fives Error

Head 19 20 ⫺1 3 9 ⫺6 2 2 0
Arms 17 16 1 17 18 ⫺1 13 10 3
Trunk 33 32 1 38 36 2 48 50 ⫺2
Legs 31 32 ⫺1 42 36 6 37 40 ⫺3

Note. The three rules minimize error for estimating surface area for the three major body size classifications. For infants (⬍10 kg) the data
are from Boyd [8]; for children and adults (10 – 80 kg) and for obese adults (⬎80 kg) the data are from the measurements performed in the
current study.
LIVINGSTON AND LEE: MEASUREMENT OF BURN SURFACE AREA 109

TBSA estimating formulas that are fairly accurate for

most patients can be derived. However, as people be-
come obese, fat accumulates disproportionately. Since
none of the prior studies included obese patients we
performed detailed body surface area measurements in
a series of obese patients. These results demonstrated
that for obese patients the trunk contributes almost
50% of the total body surface area with smaller surface
areas from the arms and legs. For this reason we
propose a “rule of fives” for estimating TBSA for obese
patients (Fig. 2B). This rule apportions 5% of total body
surface area to each arm, 4 ⫻ 5 or 20% to each leg, and
10 ⫻ 5 or 50% for the trunk. Table 3 demonstrates that
the body surface area of the trunk increases with in-
creased weight with proportionate reductions for the
arms and legs. Previous studies from our group dem-
onstrated that there is significant covariance between
BMI and weight for weights between 10 and 80 kg [11].
BMI must be calculated. Because the rules are in-
tended to simplify TBSA estimation we indexed the
proposed rules to weight categories rather than BMIs.
The proposed rules provide reasonable estimates for
surface area for weights greater than 80 kg or BMI
⬎30.
The rule of nines provides a good estimate for the
surface area for nonobese adults and children [12] (Fig.
2A). For infants weighing less than 10 kg (or having a
BMI ⬍18) the head occupies a much greater proportion
of the total body surface area. For this reason a rule of
eights applies: 8% of the total surface area for each
arm, 8 ⫻ 2 or 16% for each arm, and 8 ⫻ 4 or 32% for
the trunk (Fig. 2C). These proposed rules are simple to
remember and provide guidance for estimating total
burned surface area during the initial stages of burn
management. When burn patients are admitted many
decisions and interventions need to be quickly per-
formed. Although precise measurement of the total
burn surface area would be ideal, in practice there
generally is not time to perform detailed measure-
ments. Yet decisions regarding admission to the hospi-
tal and the volume of resuscitative fluid are deter-
mined from estimates of the burned surface area. The
formulations propose facilitate reasonable estimates
for total burned surface area to minimize errors during
the initial stages of burn patient management. Should
precise measurement of the total burned surface area
be desired [13], the body segment surface area for
patients of various sizes presented in Table 2 will fa-
cilitate the measurement. Similarly, more precise mea-

FIG. 2. Proposed rules: (A) Rule of nines for estimating total

burn surface area for patients weighing 10 – 80 kg. (B) Rule of fives
for patients weighing more than 80 kg. (C) Rule of eights for infants
weighing less than 10 kg.
110 JOURNAL OF SURGICAL RESEARCH: VOL. 91, NO. 2, JUNE 15, 2000

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7. Du Bois, D., and Du Bois, E. F. A formula to estimate the
approximate surface area if height and weight are known. Arch.
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