wound that can be closed with autograft depends on the donor sites available and the mesh ratio used. Cosmetically and functionally sensitive areas such as the face and hands need thicker sheet autograft for wound closure.

If the burn size is large or if donor sites are scarce, then temporary wound closure with allograft, xenograft or other biological or semi-biological dressings may be required to close the rest of the wound while the donor sites heal. Standard graft dressings are applied. The grafted areas can be inspected five days later. Early inspection of the wound is recommended if there was late presentation or colonization of the excised burn wound. The authors prefer to undertake this type of total wound excision in one stage but the availability of enough surgeons is critical. Alternatively this can be done in two or three stages within the first five days following the burn. Patients with large burns need to return to the operating room for further grafting when their donor sites are healed. This is usually done on a weekly basis.

Serial wound excision and conservative management

This method is employed for larger burns where donor sites are scarce. The surgical technique is similar to that given above but the amount of burn wound excised is the amount that can be covered by meshed split skin grafts from the available donor sites.

Unexcised areas are treated with topical antimicrobials until donor sites have healed and can be reharvested, usually 7–14 days later. The unhealed areas of burn wound are susceptible to invasive wound infection before they are excised and this treatment method has a higher morbidity and mortality compared to early excision. The use of the topical antimicrobial flamacerium (silver sulfadiazine and cerium nitrate) has been reported as decreasing episodes of invasive wound infection, morbidity and mortality with this method of treatment [27].

Alternatively wounds can be treated with Acticoat with alternate day to weekly dressing changes or with daily or twice daily applications of silver sulfadiazine until wound healing is achieved. This may take up to 4–6 weeks and involve the patient in prolonged and painful periods of dressing

changes. There is a higher incidence of invasive wound infection using this method with associated deepening of the wound. Once healed there is a much higher incidence of hypertrophic scarring which can be functionally and cosmetically disabling. This method is usually reserved for patients who are thought to be unfit for surgical intervention and for smaller burns in functionally and cosmetically unimportant areas.

Full thickness burns

Full thickness burns will not heal spontaneously unless very small and invariably require skin grafting. The necrotic tissue usually requires excision and the resultant wound requires closure to reduce the risks of invasive infection and systemic sepsis. Prompt excision and wound closure reduces morbidity and mortality inpatients with such injuries.

Excision and autografting

By definition full thickness injuries will not heal spontaneously and require wound closure with split thickness autografts. On presentation it is usually best to excise these wounds in a tangential fashion and obtain wound closure with split thickness autograft. Meshed autograft is used if larger areas need closure, whereas sheet autograft is used for functionally and cosmetically sensitive areas such as the hands and face. Grafts are secured to the wounds by staples or absorbable sutures and are dressed in the standard fashion. Grafts and wounds are inspected on the second day if the initial wound was infected or heavily colonized or on the fifth day if not.

Topical antimicrobials

In patients who are elderly or unfit for surgical intervention, conservative management with topical antimicrobials can be used. The antimicrobial agent– Acticoat or silver sulphadiazine–is applied regularly until the burn eschar separates and a granulating wound is present. This usually takes approximately three to four weeks to occur and sometimes longer. This granulating wound can then be covered with

autograft to achieve wound closure. In certain cases small wounds less than 5 cm diameter can be left to heal spontaneously by wound contraction and epithelialization from the wound margins. This method of treatment usually results in a higher incidence of invasive wound sepsis, a longer inpatient stay in the burn unit and a longer time to wound healing. It is not recommended except in the special circumstances given above.

Large full thickness burns

In larger injuries ( > 10%TBSA) the treatment of choice is total excision of the burn wound and physiologic wound closure with split skin autograft, allograft and/or synthetic skin substitutes. This early aggressive surgical approach has been shown to improve mortality in selected adult patient groups with such injury [28–30] (Fig. 3).

It is a major surgical undertaking to do this in one sitting with the larger burns (greater 40% TBSA) and needs a coordinated approach from the surgical and anesthetic teams (Fig. 4). The timing of surgery post injury is critical as blood loss in the 24h post burn has been shown to be half that of surgery after this time [31]. In centers when numerous surgeons and anaesthetists are not available, total wound ex-

Fig. 3. Wound Treatment Programme for Major Burn Injury (courtesy Mr. M Lloyd MRCS). 1) Following admission total/ near total wound excision is undertaken within 24hrs of injury. 2) Wound closure achieved with auto/allograft or skin substitute 3) Wound care until donor sites are healed

4) Process repeated

Fig. 4. Total Burn Wound Excision. A Patient completely exposed on operating table; B Total body prep with povidone iodine (Note thermal ceiling to maintain temperature);

C Infiltration with Adrenaline solution (1/1 x 106); D Two surgical teams – limbs elevated. E Wound excision; F Temporary wound closure with Biobrane®

cision can be staged over two to three operations removing the wound within five days of the injury.

The type of wound excision depends on the state of the burn wound. Those patients presenting immediately following their injury usually have an uncolonized wound, which can be excised in a tangential fashion with a skin graft knife.

Those patients presenting late five or more days after injury will have a colonized or infected wound. Attempts to preserve subcutaneous fat in these cases usually fail and can lead to invasive systemic sepsis; therefore fascial excision is usually preferred.

After total wound excision the whole wound must be physiologically closed with autoor allograft or a synthetic skin substitute like Integra . In large and massive burns special techniques such as overlay grafting are used to cover large wound areas with widely meshed autograft [32] (Fig. 5). In these burns where wound closure cannot be achieved primarily with autograft, the patient returns to the operating room when the donor sites are ready for reharvesting atwhichtimeallograftischangedandfurtherautograft