surgical excision of the burn wound
TRANSCRIPT
Surgical Excisionof the BurnWound
Michael J. Mosier, MD, Nicole S. Gibran, MD*KEYWORDS� Surgical excision � Burns � Blood loss� Excision and grafting � Hemostasis � Autograft� Allograft � Skin substitute
Significant advances in burn care over the lasthalf-century have allowed better understandingof the pathophysiology of thermal injury and thelocal and systemic effects that accompany suchinjury. With a multifaceted team approach toburn care that draws on the cooperation ofnursing, pharmacy, social work, occupationaland physical therapy, and anesthesia clinicianshave improved treatment strategies for the hyper-metabolic response to traumatic injury,1–3 fluidresuscitation,4,5 burn wound infection,6,7 nutri-tional support,8,9 and lung protective strategiesfor acute lung injury.10 Although each of theseadvances has contributed to the ability to carefor thermally injured patients, early excision andcoverage of the burn wound has had the greatestimpact on survival of patients with major burninjuries.
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HISTORICAL EVOLUTION ANDADOPTIONOF EARLY EXCISION OF THE BURNWOUND
Surgical excision of burn wounds was not fullyappreciated until the mid-1900s. Before thattime, burn wounds were largely treated medically.Whereas numerous topical therapies were appliedto the burn eschar, it was left intact over the woundsurface and proteolytic enzymes produced bymigrating neutrophils and bacteria within thecontaminated eschar caused a natural separationof the eschar from the wound bed. In partial-thick-ness injuries, the burn wound could naturally healfrom epidermal appendages by this process.With full-thickness burns, however, the separationof burn eschar left an open wound covered by
Department of Surgery, Harborview Medical Center, UnivAvenue, Box 359796, Seattle, WA 98104, USA* Corresponding author.E-mail address: [email protected] (N.S. Gibran).
Clin Plastic Surg 36 (2009) 617–625doi:10.1016/j.cps.2009.05.0060094-1298/09/$ – see front matter ª 2009 Elsevier Inc. All
highly vascularized granulation tissue that servedas the first early bed for subsequent grafting. Thewound closure process was long, pain was signif-icant, and hypertrophic scarring and contractureswere common.
An historic advantage to this technique of de-layed surgical treatment of the burn wound wasthe ability clearly to distinguish the areas thatwould heal without surgical treatment from thosethat would require grafting for healing to occur.This delay in surgical wound closure, however,involved extensive bacterial wound colonizationwith increased likelihood of burn wound sepsis,multiorgan system failure, and death.11–14
Early excision and skin grafting of small burnwounds was described in 1891 by Lusgarten;15 itwas not until the Cocoanut Grove fire in 1942that Cope and coworkers16 suggested thatpatients treated with early excision and graftinghad a better overall outcome. In the late 1940sand 1950s, attempts by Cope and coworkers,16
Young,17 McMillan and Artz,18 Jackson,19 andWhittaker20 to excise burn eschar ranging from3% to 30% total body surface area (TBSA) werediscouraging. Finally, with Janzekovic’s21 reportedgood results with surgical burn wound excision,enthusiasm for early excision was rekindled19–21
and as clinical experience with early excisionincreased, the benefits became clear.
Jackson’s22 description of the concentric, three-dimensional zones of thermal tissue injury,including the central zone of coagulation, thesurrounding zone of stasis, and the outermostzone of hyperemia, formed the foundation forBoykin’s and coworkers23 observations of
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progressive microvascular compromise in the zoneof stasis. Together, these observations led toappreciation of the need for early removal of thenonviable eschar, the substrate for bacterial growthand source of inflammatory mediators.24–26 Devel-opment of an aggressive surgical approach waslimited, however, by difficulty in assessing burndepth and concern about excising potentiallyviable dermal tissue. Janzekovic21 addressed thisconcern in the 1960s by developing the techniqueof tangential excision of the burn wound. Usingthis technique, she shaved successive layers ofburn eschar until reaching viable tissue withpinpoint arteriolar bleeding. This techniqueallowed for improved intraoperative assessmentof burn depth and for definitive wound closure atthe same operative setting.
Monafo and coworkers27,28 introduced theconcept of tangential excision to the United Statesand it was rapidly adopted for treatment of burns ofindeterminate depth. As experience grew, advan-tages of more rapid healing, decreased bloodloss, shorter hospital stays, and decreased hyper-trophic scarring were described. Burke andcoworkers29,30 contributed early to the philosophyof early excision of the burn wound with reports ofresults of total excision of full-thickness burns in1974. They found that mortality of adult burnpatients declined from 24% in 1974 to 7% in 1979to 1984 after they instituted the approach of prompteschar excision and immediate wound closure.31
Limited early excision of eschar rapidly progressedto staged, total excision of the burn wound.
In the early 1980s, Engrav’s32 randomized,prospective trial verified that early excision andgrafting of deep second-degree burns less than20% TBSA led to decreased length of stay andearlier return to work with less hypertrophic scar-ring compared with conventional nonoperativemanagement. As early excision and grafting waspracticed with increasing frequency across burnsizes, the beneficial effect on pulmonary function,attenuation of the systemic response to endotoxin,and tolerance in the elderly was encour-aging.2,14,31,33–37 Multiple studies repeatedly veri-fied favorable outcomes with progressively earlierwound excision and closure.14,29,31–34,37–42 By the1990s, early staged burn excision after completionof burn resuscitation and patient hemodynamicstability typically allowed for the first operativeintervention on the third postburn day.43,44
New immunologic research in the 1990s beganto shed light on the role of inflammatory mediatorsfueling a systemic inflammatory responsesyndrome that mimics sepsis and potentiallyextends burn injury. Improved understanding ofthe systemic inflammatory response syndrome
suggested that immediate removal of dead andseverely damaged tissue can interrupt and atten-uate systemic inflammatory response syndromeand normalize immune function.2,24
With improved understanding of the benefits ofattenuating the systemic inflammatory responsesyndrome came questioning of the long-held beliefthat primary excision of the burn wound before thediuretic phase of resuscitation was hazardous ina hemodynamically unstable patient. Sorensenand coworkers45 first reported total primary exci-sion of major burn injuries within 24 hours aftera burn injury in 1984, but was discouraged bydifficulty in providing an adequate donor bloodsupply and in immediate availability of surgicalservices. In a subsequent study, Herndon andcoworkers41,46 confirmed the safety of stagedprimary excision in adults completed within72 hours postburn injury and popularized earlymassive excision of an entire burn wound inseverely burned children with cadaveric skincoverage. His review of 64 patients documenteda significantly shorter length of hospitalizationand fewer operations with early massive excisionbut no difference in mortality; long-term morbiditywas not evaluated.
It has been further suggested that excision ofthe burn wound within 24 hours postburn is asso-ciated with decreased bleeding, likely caused byhigh levels of local and systemic vasoconstrictivemetabolites.47–51 Similarly, Still and coworkers52
showed decreased length of stay and cost savingswith immediate primary excision of the burnwound in a large adult series.
WOUND EXCISION
Based on these historical advancements andimproved understanding of altered physiologythat accompanies thermal injury, conventionaltreatment for major full-thickness burns nowconsists of early staged excision, routinely begin-ning as early as the third postburn day if feasible.Operations can be spaced 2 to 3 days apart untileschar is removed and wound coverage isachieved. The principle is to remove all eschar aspromptly as possible. Debrided wounds can becovered with autograft, temporary biologic dress-ings, cadaveric allograft, or dermal replacement(Integra), until autologous donor sites are avail-able. A widely accepted definition of ‘‘early’’ hasnever been defined, but surgeons should aim tocomplete excision wounds that clearly do notheal within a week after injury.
The decision to perform operative woundexcision is typically guided by whether or notspontaneous wound healing will occur within 2 to
Surgical Excision of the Burn Wound 619
3 weeks postburn. Burn wounds over jointsurfaces should be excised and grafted soonerto minimize wound contraction that ultimatelyleads to disabling contractures. Patient hemody-namic and pulmonary status must be consideredin deciding on timing for operation. The risk ofhypothermia and the need for blood transfusionshould be anticipated before surgery and commu-nicated to the anesthesiologist.
There are two approaches to surgical excision ofthe burn wound: fascial excision and tangentialexcision. Fascial excision involves excising theburned tissue including full-thickness of skin andsubcutaneous fat to the layer of investing fascia.The advantages of fascial excision include aneasily defined well-vascularized plane (Fig. 1A)that readily accepts a graft. Fascial excision canbe easily performed with electrocautery, mini-mizing blood loss, and blood vessels can be easilyidentified and coagulated or ligated. The principaldrawback is that healthy, viable subcutaneoustissue and dermal elements including lymphaticsare included in the excision. Advancing the skinedges and tacking them to the fascia with absorb-able suture reduces the contour discrepancy andoften decreases the wound area that requiresgrafting (Fig. 1B). Nevertheless, fascial excision
Fig.1. (A–C) Fascial excision Arrow denotes well vasculariz
causes notable tissue depression with unaestheticcontour deformities and often lymphedema(Fig. 1C). Given these disadvantages, fascialexcision is often reserved for very large, deeplife-threatening burns or for life-threatening inva-sive wound sepsis, particularly with fungus, yeast,or mold.
Tangential excision removes necrotic tissuewhile preserving as much of the underlying viabletissue as possible. Body contours are betterpreserved than with a fascial excision and it isa more cosmetic excision and the preferredmethod for smaller burns. With tangential excision,layers of eschar are sequentially excised untila layer of viable, bleeding tissue (Fig. 2) capableof supporting a skin graft is encountered.21,27,28
The goal is to remove only the nonviable tissue,particularly in the case of deep dermal wounds.Typically, tangential excision is performed witha hand-held knife (Goulian, Weck, Humby, or Wat-son) with an adjustable guard to control for thedepth of excision (see Fig. 2). A back and forthmotion, similar to a bow on a violin, with very littleforward force and slight downward pressuregenerates a smooth excision. Tension on thewound and countertraction on the eschar facilitatethe removal. Care must be taken with tangential
ed fascia during a facial excision.
Fig. 2. Tangential excision.
Mosier & Gibran620
excision because the blades can easily create full-thickness incisions regardless of guard depth.
Diffuse punctate bleeding is the hallmark ofa viable wound bed. The points of capillary andarteriolar bleeding are closer together in the upperpapillary dermis and more widely separated in thedeeper reticular dermis and subcutaneous adiposetissue. If a tourniquet is used to reduce bleeding,recognizing tissue viability may be more chal-lenging. It is important that excision continues layerby layer until either healthy fat or a moist, whitedermal surface is identified. Viable dermal bedsshould be uniformly white and moist, and healthyfat has a yellow glistening appearance. Grafts failon wound beds with remaining dullness, echymo-sis, or thrombosed vessels. Any hemoglobin-stained layers of the dermis, and gray or brownareas of the subcutaneous tissue indicate nonvi-able tissue and require deeper excision.
CONTROLLING BLOOD LOSS
A main disadvantage of tangential excisioncompared with fascial excision or delayedexcision has been potential blood loss.29,49,53–57
Since the popularization of early excision andgrafting, efforts have focused on methods toreduce intraoperative blood loss. This is especiallyimportant because adequate hemostasis is criticalbefore the placement of skin grafts, cadavericgrafts, or skin substitutes to minimize hematomaformation and prevent graft loss, and minimizethe need for blood transfusions. Typically, the totalarea of excision at any one time should be limitednot only to control blood loss but also to preventhypothermia.
A wide variety of techniques intended to reduceintraoperative blood loss have been described.These have included application of topicalepinephrine with or without thrombin to excised
wounds and donor sites, the subcutaneous infiltra-tion of vasoconstrictors, and the use of tourni-quets. The authors have found the combinationof each of these techniques to reduce blood losssignificantly, as has been reported in severalstudies.58–60
The authors find the use of topical vasoconstric-tion with epinephrine (1:10,000) soaked telfa pads,predebridement tumescence with weak epineph-rine solution (1:500,000) into the burn wound anddonor sites, and the use of tourniquets inflated to250 mm Hg pressure on the extremities to be themainstay of hemostasis along with direct pressureand cautery when necessary for punctatebleeders. The primary concern about this tech-nique that has been raised is the unreliability ofcapillary bleeding to determine wound bed viabilityand the disadvantage that injection needle trackscan cause an echymosis that can be difficult todifferentiate from the burn injury; however, theassessment of tissue viability with these tech-niques is less difficult than may be expected, aslong as the following principles are observed: thedermis must be pearly white, with no hemorrhagicstaining; minor vessels on the wound surface mustbe patent; the fat must be pale yellow, firm, andmoist; and the excised wound rapidly becomeshyperemic, even under tourniquet control.58 Aswith all procedures performed under tourniquet,attention to the clock should limit ischemia timeto less than 120 minutes.
Modulation of the coagulation cascade withtopical thrombin or fibrinogen-thrombin has beendescribed for over 20 years. The thick fibrin clotsthat irregularly coated the wound bed, however,limited effectiveness. It was not until introductionof aerosolized delivery of fibrinogen-thrombinsolutions that this surgical intervention benefitedexcision and grafting.61–63
Immediate coverage of an excised burn woundwith an autograft, allograft, or xenograft is ideal.The option of delayed grafting potentially leavesthe ungrafted, exposed tissues at risk for desicca-tion, infection, and progressive thrombosis unlessthe wound is kept moist and clean. Options fortemporary and permanent closure of the excisedburn wound are discussed elsewhere in this issue.
LARGE BURNS
Patients with deep burns between 50% and 70%TBSA provide many challenges, often requiringseveral operations to excise the wound and limiteddonor sites to provide coverage. Once the patienthas completed resuscitation, all full-thicknessburn wounds should be excised as tolerated withinthe first several days after injury to reduce the
Surgical Excision of the Burn Wound 621
inflammatory response and risk of burn woundsepsis. Safe management of a patient undergoinga massive burn debridement requires good coop-eration and communication between all membersof the operating room team, including the surgeon,anesthesiologist, surgical assistants, scrub nurse,and circulating nurse. The operations can be long,bloody, and demanding for both patient and staff.It is imperative to make every effort to maintainnormal body temperature, because the patient isoften completely exposed with little intact skinand impaired thermal regulation. Methods thatcan be used to limit heat loss include warming theroom to 32�C to decrease evaporative losses,covering all areas that do not need to be exposedwith a Bair hugger and warm blankets, and adminis-tering warmed intravenous fluids. Maintainingtemperature over 33�C has been associated withdecreased infection in other elective surgeries,64–68
but has not been clearly validated with burns.Hypothermia, however, aggravates coagulationand complicates postoperative resuscitation.
One widely adopted approach to staged woundcoverage is to excise as much burn as possibleand cover the viable wound bed with a dermalsubstitute or allograft. Definitive wound coverageof functionally important sites, such as the hands,should take precedence to minimize immobiliza-tion time and allow rehabilitation to proceed aspromptly as possible. The patient should returnto the operating room as soon as donor sites arehealed for further autografting or for replacementof nonadherent allograft or skin substitute.
Whenever possible, sheet grafts should be usedfor coverage of excised burns. For burns under20% TBSA, coverage with sheet graft should bea priority, especially in children. With rare excep-tion sheet grafts should be used for hand woundcoverage and almost always for face grafts. Forlarger burns that require use of meshed graft,mesh expansion should be minimized wheneverpossible especially for exposed areas, such asarms, legs, and shoulders. One traditionalapproach to wound coverage for patients withmajor burns (>40% TBSA) has been applicationof sheet grafts for the face and hands and use ofwidely meshed autograft (4:1) to wounds or toneodermis on the back, abdomen, buttocks, andupper thighs with an allograft overlay to protectthe interstices.
Fig. 3. Wound Vac immobilizing neck and chest grafts.
POSTOPERATIVE DRESSING OPTIONS
The excised bed on which a skin graft is placedmust be kept moist, warm, and bacteria free untilthe graft attaches itself and becomes vascular-ized. When meshed grafts are used, the bed
must also be protected until the interstices of themesh epithelialize. This can be done with a lightdry (or greasy) dressing, such as Conformant,over the autograft. For grafts that are difficult todress, such as the back, axilla, or breast, Acticoator Aquacel Ag can be applied or a Wound-Vac(Fig. 3) can be placed to splint the graft site andto apply negative pressure. For torso grafts,suturing a thick absorbent dressing, such asExuDry, with 0-0 nylon suture prevents shearingduring the immediate postoperative period. Thesedressings can often be left in place for 5 to 7 days,especially if used with an antimicrobial dressing.
For smaller grafts, Hypafix tape effectivelyaffixes a graft, often eliminating the need forstaples, even over contoured areas, such as theneck. If used, it should be left in place for 7 days,then soaked in vegetable oil or orange solvent sothat it can be easily peeled off the graft. If woundsare colonized at the time of excision and grafting,or if they are extensive enough to be life threat-ening if they were to become infected, the graftshould be dressed with a wet antimicrobial;Sulfamylon 5% solution provides broad-spectrumcoverage for both grafts and donor sites unless thepatient has a sulfa allergy and develops a rash, inwhich case 0.5% silver nitrate solution or0.025% Dakin’s solution can be used. Dressingsprotect the freshly applied grafts until they areadherent, which typically occurs at 5 days. Dress-ings on dirty wounds, or grafts next to unhealedburns, may need to be changed on the first post-operative day. A dressing change on postopera-tive day 1 may also be necessary for sheet graftsto check for hematomas or seromas, which shouldbe incised and drained to ensure graft adherence;intraoperative ‘‘pie-crusts’’ generally do notprevent collections. Dressings for most grafts,however, can usually be left in place for 5 to 7days. During this time, strict immobilization is
Mosier & Gibran622
essential to prevent sheering if the graft is near orover a joint.
OPERATIVEMANAGEMENT OF SPECIAL AREASFace
Because the vascularity of the face rapidlydissipates heat, many facial burns are partialthickness and warrant observation for 10 days toallow for spontaneous healing.69,70 An aggressiveapproach to early debridement may speed healingand reduce scar formation.71–74 Superficialdebridement using a Norsen blade 7 to 10 daysafter injury may indicate whether the skin is likelyto heal. If the debridement demonstrates punctatebleeding throughout the wound bed, grafting maybe delayed. Deep dermal facial burns have beenshown to be more prone to hypertrophic scarringif they take more than 18 days to heal;71 surgeryshould be performed before this period if thewound has not already healed. Prolonged healingof hair-bearing areas is an additional problembecause folliculitis, which incites hypertrophicscarring, is a common sequela.
Surgical approach to obvious full-thicknessfacial burns is often simpler than deep dermalburns with patches of full-thickness injury. A faceburn that obviously needs operative therapy canbe scheduled for surgery as soon as edemasubsides. The surgeon must consider theaesthetic units of the face before undertaking exci-sion of facial burns. If part of a cheek must beexcised, the surgeon must decide whether a patchis aesthetic or whether the patient is best off withexcision of the entire cheek.
Face excision can be particularly bloody,because the face has a generous blood supply.Nevertheless, tangential excision with a Goulianknife is preferred to preserve as many viabledermal elements as possible, and achievea more cosmetic result. Excision requiresremoving all hair follicles, because graftinga partial-thickness wound with hair protrudingthrough the graft leads to infection and inflamma-tion with resultant graft loss and hypertrophicscarring.
Sheet grafts should be used almost exclusivelyfor coverage of face wounds. Donor skin shouldbe selected from a site that closely resemblesfacial skin in depth and color. As such, skin fromabove the nipples is often preferred. Skin fromthe scalp is ideal if it provides sufficient graft tocover the wound. Harvesting the scalp requiresslightly more attention to detail, includingtumescence with epinephrine (1:500,000), but ittheoretically provides a donor site that can becompletely hidden when the hair regrows. One
potential disadvantage is the risk of alopecia andhair growth in transplanted areas if the graft isharvested too deep.
Deep burns to the eyelids should be excised andgrafted early, preferably with full-thickness skingrafts. Delay leads to cicatricial ectropion, cornealexposure, bacterial superinfection, and threatenedvision.75 If postburn cicatricial ectropion occurs,release and full-thickness grafts to the lower lidand thick, split-thickness grafts to the upper lidsshould be undertaken as soon as possible. Defin-itive reconstruction should be performed at a laterstage, when scars have matured.
Genitals
Superficial, partial-thickness burns to the genitalsare best treated expectantly, with spontaneoushealing the typical result. Perianal burns seen inassociation with severely burned adults or scaldedchildren can be a challenge, given the risk for fecalcontamination. Under rare circumstances,consideration for a temporary or even permanentcolostomy should be included especially if thesphincter is burned. Alternatively, pharmacologicintervention can maintain liquid stool, which canbe managed with a rectal tube.
The scrotum even when it is completely burnedheals well with daily wound care and application oftopical antimicrobials. Also, most penile burns canbe managed nonsurgically with topical antimicro-bials. If the foreskin is deeply burned, circumcisioncan be performed to prevent phimosis. Allowingfor eschar separation and secondary grafting ofthe granulation tissue ideally treats a deep burneschar to the glans, because significant bleedingcan occur with surgical debridement. Likewise,burns to the labia majora can be delayed untilhair-bearing areas have declared themselves asnonhealing. For all perineal burns, the urinarycatheter should be removed as soon as possibleto avoid urinary tract infections.
Hands
Surgery is indicated for any deep dermal or full-thickness dorsal hand burn that does not healwithin 14 to 21 days. Timing of operation shouldbe influenced by overall condition and woundsize. Inadequate excision is a common reasonfor graft failure, which impairs participation intherapy and delays full functional recovery. Deeppartial-thickness and full-thickness burns of thehands generally require tangential excision andautografting. To minimize blood loss, excisionshould be performed under tourniquet inflation.
Full-thickness burns should be excised andgrafted as soon as practical to subcutaneous
Surgical Excision of the Burn Wound 623
tissue; retention of epidermal appendages causesinclusion cysts under the grafts and leads to indo-lent infections and graft loss. Thick split-thicknesssheet grafts should be used whenever possible. Inone study, however, blinded observers could notdistinguish a difference between 15/1000-in or25/1000-in skin graft, and thinner grafts have theadvantage of less donor-site morbidity.76 Applica-tion of Integra as a dermal substitute to theexcised wound with delayed autografting can beperformed with good cosmetic and functionalresult.77
SUMMARY
Early excision of the burn eschar has been one ofthe most significant advances in modern burncare. Historical advances in understanding of thepathophysiology of burn injury and the systemicinflammatory response fueled by the burn wound,and refinements in the techniques of tangential andfascial excision, have led to earlier excision andgrafting of the burn wound with improvements inmorbidity and mortality. Efforts to control bloodloss, ensure adequate wound bed viability, andmaximize graft adherence with fibrin sealants andimmobilization promote safe and effective earlyexcision and grafting of large burns.
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