5.1Introduction

During the past decades, burn care has improved to the extent that persons with burns can frequently survive (Fig. 5.1). The trend in current burn care extends beyond the preservation of life; the ultimate goal is the return of burn victims, as full participants, back into their families and communities.

5.2Burn Wound Evaluation

One of the major problems that face any burn surgeon is the decision on the nature of treatment (conservative treatment versus operative treatment). In the case of an operative procedure, a decision is needed on when and how to excise the burn wounds and to determine accurately the depth of the lesion and thereby the extent of tissue involvement.

5.3Escharotomy/Fasciotomy

One of the most important indications for an immediate surgical intervention is the presence of a compartment syndrome. Circumferential burns have a high risk to develop compartment syndrome. Compartment syndrome can occur in circumferential upper and lower extremity burns, but escharotomy may be necessary also to relieve chest wall restriction in order to improve ventilation.

L.-P. Kamolz, MD, PhD, MSc

Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria

e-mail: lars.kamolz@medunigraz.at

Fig. 5.1 Factors which had major impact on survival. The 50 % survival rate has increased from 35 % TBSA to 80 % TBSA within the past decades

5.4Surgical Burn Wound Management

The main goal of surgical treatment is the replacement of necrotic tissue. One of the main problems encountered in extensively burned patients >60 % total body surface area (TBSA) is the scarcity of harvesting areas for autologous skin grafts.

Superficial dermal burns will heal without operation within 2–3 weeks, but deep dermal and full-thickness burn will require operation. It is widely accepted that if skin does not regenerate within 3 weeks, morbidity and scarring will be severe, so the trend in the treatment of deep dermal and full-thickness burns leans toward very early excision and grafting in order to reduce the risk of infection, decrease scar formation, shorten hospital stay and thereby reduce costs.

Excision of as much of the necrotic tissue as possible should be carried out whenever a patient is hemodynamically stable and the risks of the operation would not increase the mortality that would be expected from the traditional treatment. In patients with associated injuries such as inhalation injury, patients of extreme age, or patients with cardiac problems, special surgical treatment is required in deciding when and how much to excise.

Sequential layered tangential excision to viable bleeding points, even to fat, while minimising the loss of viable tissue, is the generally accepted technique.

Fig. 5.2 Mixed dermal burn—tangential excision of the deeper parts and coverage with Suprathel®, late results

Excision of burn wounds to the fascia is reserved for large burns where the risks of massive blood loss and the possibility of skin slough from less vascularised grafts on fat may lead to higher mortality.

We start to excise all deep dermal and full-thickness burned areas within 72 h of injury. It has become apparent that early excision is better than late excision, because after 7 days the incidence of sepsis and graft failure increases:

In case of deep dermal injuries, after tangential excision the resulting defects can be covered with keratinocytes, autologous or allogeneic skin grafts or by use of synthetic materials like Suprathel® (Fig. 5.2).

In case of full-thickness burns, we dominantly use autografts to cover the wounds if there are sufficient available donor sites. In large burns we normally use expanded autografts (mesh or Meek).

Expansion rates of graft to wound area cover ranges from 1: 1 to 1: 9. Expansion rates higher than 1: 3 heal in a suboptimal manner leading to contractures and unstable scars. Therefore, we like to combine these large meshed autografts in combination with allografts (Fig. 5.3) or keratinocytes (sandwich technique), or we will use the Meek technique (Fig. 5.4). In functional important regions like hands and over joints, a combined reconstruction of skin by use of a dermal matrix (Integra®, Matriderm®), and split-thickness skin graft seems to be superior to skin grafts alone (Fig. 5.5).