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A cornerstone of modern burn treatment is early excision, in which eschar is removed surgically before it can separate. Early excision and skin grafting of burn wounds reduces time in hospital and costs, improves functional and cosmetic outcomes, promotes early rehabilitation, relieves suffering, and almost certainly improves survival. Excision removes the eschar which causes much of the inflammatory response to burn injury and serves as a source of burn wound infection. The incidence of burn wound sepsis has declined dramatically since the widespread adoption of early excision.

Two common techniques are used for excision (Saffleand S.c,h.D.e,b.!.y...,1..9.94.). Full-thickness, or fascial, excision of the skin and subcutaneous tissue to the level of muscle fascia is easy to perform, produces relatively little bleeding, and facilitates graft 'take'. However, removal of subcutaneous fat is disfiguring, and loss of padding around joints results in prolonged stiffness and discomfort. Fascial excision is frequently used for very deep extensive burns, particularly of the trunk; it can also be helpful in treating elderly patients, whose subcutaneous tissues may not support skin grafts. ( CD Figure.. . .2) In tangential or layered excision, thin slices of eschar are removed with a dermatome until punctate capillary bleeding indicates viable tissue. Tangential excision requires experience and judgment to perform successfully. Bleeding from exposed capillary beds can be profuse and hard to control. Tangential excisions are ideal for deep partial-thickness injuries, in which small amounts of deep dermis can be salvaged. Such wounds accept grafts exceptionally well and scar relatively little. This technique is preferred for wounds of indeterminate depth, and for any areas (hands, face, etc.) where appearance and function must be optimized. ( ,C.D...,F.i.,g..u..r.e 3,)

CD Figure 2. Fascial excision and widely meshed skin grafting. (a) To treat this patient with a massive (65 per cent TBSA) full-thickness burn, the entire torso is excised to fascia using scalpels and electrocautery. Once hemostasis is achieved, the wound is covered with a combination of widely meshed split-thickness autograft, over which is laid narrowly meshed cadaver allograft. The cadaver skin helps to protect the underlying autograft from motion, infection, and dessication while its interstices fill in. (b) The same patient several months later. The autograft has closed the wound completely, and the cadaver allograft has gradually dissolved. The patient has good skin quality and mobility.

CD Figure 3. Tangential excision and sheet skin grafting. (a) This patient presented with a deep partial-thickness burn of the dorsal hand and forearm. Under occlusive tourniquet, tangential excision is used to remove thin strips of eschar until viable dermis and subcutaneous fat are revealed. An area of discoloration, which requires additional excision, is indicated; other such areas can be seen overlying the metacarpophalangeal joints. When the whole wound has been adequately excised the tourniquet is released, immediately revealing punctate bleeding over the entire wound surface. (b) Once hemostasis is achieved, the wound is grafted with sheet split-thickness autograft. This maximizes cosmetic appearance and function, and minimizes scarring. The hand is shown several months after grafting; the "seams" between sheets of skin can be seen.

Once excised, burn wounds must be covered quickly or desiccation will produce a new layer of eschar. Split-thickness autograft is the cover of choice, but a growing variety of temporary coverings are available, including fresh and frozen cadaver allograft skin, acellular allodermis, porcine heterograft, collagen-impregnated silastic, and a variety of synthetic dermis-like coverings, some of which can be left in place permanently for eventual coverage with thin autografts or cultured epidermis.

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