Surgical Treatment of Burns

Debridement

Surgical treatment of burns begins with debridment (cleaning and clearing) of the necrotic tissue from the wound bed. This debridement reduces the incidence of infection and also serves to decrease the inflammatory response (when compared to what the inflammatory response would be with the necrotic tissue remaining). The sooner this debridement takes place the better. Surgical debridment or removal of eschar commonly occurs in the operating room but some of this debridement will be a continuous process that continues throughout the patient's stay. Obviously removal of this necrotic tissue will leave large percentages of the body open. These open areas need to be closed in order to facilitate healing and prevent infection. Skin grafting is used to close these open wounds (Sanford & Herndon).

Types of Skin Grafting

Autograft: skin taken from one area of the burn victim's body that is grafted over the open burn wound

• Four-to-one mesh grafting is often practiced with patients that have large TBSA burns. Little incisions are made in the graft taken from the patient and the skin is stretched to cover approximately four times the area from which it was taken (hence the name four-to-one mesh). While this makes very effective use of the donored skin, its main drawback is that it does not heal as uniformly as normal one-to-one autograft. 

Healed 4:1 Mesh Autograft

Allograft: skin transplant from another person

• The tissue taken from another individual (typically from a cadaver) needs to be viable or alive. These allografts are often rejected by the burn patient's body within 10 days at which point autografting or skin substitutes are applied if needed.

Xenograft: skin taken from another species, typically from pig

• Xenograft is not expected to adhere and grow into the burn patient's natural skin. It's purpose is to provide a desirable environment for healing. Once the burn patient's immune system rejects the xenograft it will be mechanically removed. In my experience, xenograft is the grafting form that is used most commonly for burn patients with very large TBSA burns.

Synthetic skin: manufactured by man

• There are different types of synthetic skin. For example, Integra is synthetic skin that is manufactured using proteins from cows (collagen) and carbohydrates (Halim, Khoo, & Mohd. Yussof).

Escharotomy

When full thickness burns are circumferential escharotomy may need to be performed. When the entire (or near entire) circumference of a body part is damaged by full thickness burns the tissue becomes rigid and less pliable than healthy, viable skin. This added rigidity, in addition to increased interstitial edema, results in internal body pressures that are sustainable. If the pressure is not relieved blood flow can be limited. If full thickness burns encapsulate the areas of the neck, chest, and abdomen the patient may no be able to breath due to the lack of compliance that is normally found in the thorax and neck. Escharotomy is the process of making elongated incisions through the eschar (non-viable tissue) in order to provide the tissue with the flexibility needed to sustain blood flow, respirations, and cellular life (Pal par 1-3).

 

Works Cited

Halim, A. S., Khoo, T. L., & Mohd. Yussof, S. J. (2010). Biologic and synthetic skin substitutes: An overview. Indian Journal of Plastic Surgery : Official Publication of the Association of Plastic Surgeons of India, 43(Suppl), S23–S28. doi:10.4103/0970-0358.70712  

 

Pal, N. (2015, May 4). Emergency Escharotomy. In Medscape. Retrieved May 6, 2015, from http://emedicine.medscape.com/article/80583-overview

Sanford AP, Herndon DN. Current therapy of burns. In: Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001. Available from: http://www.ncbi.nlm.nih.gov/books/NBK6954/

Images

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