Surgical Excision of the Burn Wound

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Historical evolution and adoption of early excision of the burn wound

Surgical excision of burn wounds was not fully appreciated until the mid-1900s. Before that time, burn wounds were largely treated medically. Whereas numerous topical therapies were applied to the burn eschar, it was left intact over the wound surface and proteolytic enzymes produced by migrating neutrophils and bacteria within the contaminated eschar caused a natural separation of the eschar from the wound bed. In partial-thickness injuries, the burn wound could naturally heal from epidermal

Wound excision

Based on these historical advancements and improved understanding of altered physiology that accompanies thermal injury, conventional treatment for major full-thickness burns now consists of early staged excision, routinely beginning as early as the third postburn day if feasible. Operations can be spaced 2 to 3 days apart until eschar is removed and wound coverage is achieved. The principle is to remove all eschar as promptly as possible. Debrided wounds can be covered with autograft,

Controlling blood loss

A main disadvantage of tangential excision compared with fascial excision or delayed excision has been potential blood loss.29, 49, 53, 54, 55, 56, 57 Since the popularization of early excision and grafting, efforts have focused on methods to reduce intraoperative blood loss. This is especially important because adequate hemostasis is critical before the placement of skin grafts, cadaveric grafts, or skin substitutes to minimize hematoma formation and prevent graft loss, and minimize the need

Large burns

Patients with deep burns between 50% and 70% TBSA provide many challenges, often requiring several operations to excise the wound and limited donor sites to provide coverage. Once the patient has completed resuscitation, all full-thickness burn wounds should be excised as tolerated within the first several days after injury to reduce the inflammatory response and risk of burn wound sepsis. Safe management of a patient undergoing a massive burn debridement requires good cooperation and

Postoperative dressing options

The excised bed on which a skin graft is placed must be kept moist, warm, and bacteria free until the graft attaches itself and becomes vascularized. When meshed grafts are used, the bed must also be protected until the interstices of the mesh epithelialize. This can be done with a light dry (or greasy) dressing, such as Conformant, over the autograft. For grafts that are difficult to dress, such as the back, axilla, or breast, Acticoat or Aquacel Ag can be applied or a Wound-Vac (Fig. 3) can

Face

Because the vascularity of the face rapidly dissipates heat, many facial burns are partial thickness and warrant observation for 10 days to allow for spontaneous healing.69, 70 An aggressive approach to early debridement may speed healing and reduce scar formation.71, 72, 73, 74 Superficial debridement using a Norsen blade 7 to 10 days after injury may indicate whether the skin is likely to heal. If the debridement demonstrates punctate bleeding throughout the wound bed, grafting may be

Summary

Early excision of the burn eschar has been one of the most significant advances in modern burn care. Historical advances in understanding of the pathophysiology of burn injury and the systemic inflammatory response fueled by the burn wound, and refinements in the techniques of tangential and fascial excision, have led to earlier excision and grafting of the burn wound with improvements in morbidity and mortality. Efforts to control blood loss, ensure adequate wound bed viability, and maximize

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      The granulated tissue underneath the eschar is then covered with split thickness skin graft (STSG). Delaying surgery can be advantageous as it differentiates areas that can heal without surgery from those that require grafting [6]. This approach is applied in European countries [7].

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