What is the role of excision and grafting in the treatment of the burn patient?

Updated: Jan 10, 2018
  • Author: Robert L Sheridan, MD; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
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Early excision and closure of full-thickness wounds changes the natural history of burn injury, avoiding the otherwise common occurrence of wound sepsis. [41] Wound size is the most important factor in determining the need for early operation because this correlates with the physiologic threat represented by the injury. These operations can be bloody and physiologically stressful, but the blood and stress can be minimized with proper planning and execution.

A prediction regarding the probability a wound will require operative management is of enormous practical value. Examination by an experienced burn surgeon remains the most reliable method, despite the many devices developed to measure burn depth or burn blood flow. The changes in wound appearance over the first few days after injury make serial examinations particularly useful tools in surgical planning.

Patients with small burns rarely develop overwhelming wound sepsis, and burn care providers often have the luxury of time to allow the wound to fully evolve, allowing accurate operative planning. An initial nonoperative approach to such wounds helps minimize the need for operation. Patients with larger injuries generally do better if their wound is addressed during the first few days after the burn occurred. If wounds cover more than 40% TBSA, this may require staged procedures. If the wounds involve more than 50% of the body surface, achieving immediate autograft closure is often impossible. When autograft material is exhausted, temporary biologic closure is achieved with human allograft or other temporary wound closure material. Wounds are later resurfaced with autograft when donor sites have healed.

Most wounds can be managed with layered excisions that optimize appearance and function. Sheet grafts are used whenever reasonable. Blood loss associated with these operations has been estimated in the past at 3.5-5% of the blood volume for every 1% of the body surface excised. However, less blood loss can be achieved through the use of extremity tourniquets, dilute epinephrine injection, and a brisk operative pace. Intraoperative hypothermia should be anticipated and prevented though operating room heating.

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