limited, difficult to harvest and cosmetically and functionally important (face, hands feet, genitalia). A review of patients surviving massive burn injury showed that patients treated with CEA had a longer hospital stay, required more operations, and had a higher treatment costs compared to a comparative group of patients treated with conventional techniques [52].

Skin graft take

By definition a graft is completely removed from its donor site, loses its blood supply and requires revascularization when applied to the wound bed. Split skin grafts take on wound beds by adherence, plasmatic imbibition and revascularization. When a split skin graft is applied to a wound bed, rapid adherence is a good sign implying that the graft will take. Adherence is due to fibrin bonds, which are weak at first and can be disrupted by shear, hematoma or seroma. If serous fluid starts to leak through mesh interstices or fenestration’s immediately after graft application and the graft is adherent, good take is ensured.

Over the first 48h the graft survives by plasmatic imbibition, that is, absorption of fluid into the graft due to accumulation of osmotically active metabolites and denatured matrix proteins. This fluid may contribute to cell nutrition and may keep vascular channels within the graft open until it is revascularised. Thin grafts survive this process better than thicker ones. The graft is revascularized over a period of 3–4 days with vessel anastomoses between the wound bed vasculature and existing vessels within the graft (inosculation) and by direct fibrovascular ingrowth from the wound bed into the graft matrix forming new vascular channels.

In the initial stages graft revascularization can be prevented or disrupted by graft shear, hematoma or seroma formation. Graft shear can be minimized by non shear dressings, pressure dressings, exposure or graft quilting. Hematoma can be minimized by meticulous hemostasis following wound excision. Mesh grafting or fenestration will allow drainage of hematoma or seroma.

Adherence and subsequent take depend on the wound bed, thus freshly excised wounds take graft well with fascia better than fat. Fresh granulating

wounds also take grafts well but chronic granulating wounds and contaminated wounds have poorer graft takes due to proteolytic enzymes in the wound that can be produced by both bacteria and cells within the wound itself. In chronic granulating wounds it is not uncommon to see ‘ghosting’ of skin where initial graft take is good but then the grafts slowly ‘dissolve’ over a period of days. They can be salvaged by wound care with topical antimicrobials.

Following take the graft goes through a number of stages to achieve maturation. Initially there is epithelial hyperplasia and thickening which leads to scaling and desquamation. The epithelial appendages such as sweat and sebaceous glands do not survive grafting but can regenerate in thicker grafts. The grafts are dry and require moisturizing until these functions return. Grafts tend to be re-innervated over a period of time with sensation developing within a month but continued improvement can occur for several years.

Pigmentation of grafts can be troublesome, particularly inpatients with dark skin. Grafts can be hypoor hyperpigmented and it is difficult to predict which. In general, grafts harvested from the lower half of the body tend to be paler and can become yellow if placed above the clavicle.

The main problem with grafts is that of hypertrophic scarring and contraction. All grafts will be surrounded by a marginal hypertrophic scar. Interstices in mesh grafts will develop hypertrophic scarring and in widely meshed graft will give an unsightly appearance. The amount of wound contraction depends on the proportion of dermal thickness within the graft. Thus areas where there is no dermis, such as at the margin of grafts and in grafts interstices, hypertrophic scarringandwoundcontractionareinevitable.Wound contraction around mobile areas and anatomical landmarks can lead to contractures resulting in deformity and impairment of function.

Rehabilitation and outcome

Burn rehabilitation starts on admission to the burn service. Having a significant burn is frightening, disorientating and painful. Positioning, splintage, and control of oedema are essential to maintain range of motion and function. Active mobilization and pro-

moting functional activities are also vital and should commence on admission. Respiratory care and rehabilitation to maintain spontaneous ventilation, coughing and expectoration are important to minimize the need for mechanical ventilation and its associated complications.

Consistent repetitive and motivational education is a vital part of patient care. Patients are encouraged to share responsibility for their own management and to optimise their rehabilitative opportunities [53]. Well motivated patients can surpass expectations with regards to their functional recovery whereas poorly motivated patients can end up with poor functional outcomes despite best efforts [54]. Early exercise has been shown to be beneficial following paediatric burn injury, significantly enhancing lean mass and strength, without exacerbation of postburn hypermetabolism [55]. This work need to be repeated in an adult population to demonstrate benefit in this patient group.

Outcome following burn injury in adults has been traditionally defined in terms of mortality and length of stay. Crude mortality data are not helpful in assessing individual services performance and the Lethal Dose 50 % is the recommended assessment tool. This can be obtained by probit analysis of mortality data and signifies the %TBSA burn at which 50 % of the patients admitted to the service die. This data is available from North America where young adults (age 16 -65 yrs) have an LD50 of approximately 80 % TBSA and middle aged adults have an LD50 of over 50 % TBSA[56]. Unfortunately this data is not commonly available outside North America [57].

Length of stay is a good global surrogate measure for outcome and quality of care. If patients are admitted in a timely fashion, undergo adequate fluid resuscitation, have appropriate early surgical excision and grafting, receive satisfactory nutritional and critical care support, have good wound care and have timely physical and psychosocial rehabilitation, they will ready for discharge in a relatively short time frame. It is accepted that one day per percent burn as a goal for length of stay in their more significant injuries.

However delays may reflect complex rehabilitation, psychological or social issue that may be a barrier to discharge.

More sophisticated measurement of outcome in burns patients is complex and multi-faceted. As increased numbers of burned injured survive a more comprehensive assessment of outcome deserves high priority. Domains of assessment have been described that provide such a global view. These include (i) skin; (ii) neuromuscular function; (iii) sensory and pain; (iv) psychological function; (v) physical role function; (vi) community participation; and (vii) perceived quality of life [58]. There are many and varied measurement tools that have been used to assess these domains however further investigation is required to identify the best tools and new tools that can provide easily measurable and reproducible assessment of outcome.

Future care

Despite significant advances in burn care leading to improved survival over the past 30 years, burn injury still represents a major challenge in clinical care. Improved fluid resuscitation, respiratory care, critical care and wound management have all contributed to decreases in morbidity and mortality. However limited donor sites, infectious complications, the systemic inflammatory response leading to organ dysfunction can lead to significant morbidity and prolonged in patient stay. It has been postulated that Stem Cell therapy has the potential to modify systemic response and enhance wound healing.

Embryonic and adult stem cells have the ability to differentiate into various tissue types and a prolonged self-renewal capacity. Bone marrow, peripheral blood, umbilical cord blood, adipose tissue, skin and hair follicles, have all been utilized to isolate stem cells. Beneficial effects include acceleration of healing of acute and chronic wounds [59].

Gene therapy, initially developed for treatment of congenital defects, holds potential for enhancing wound healing and repair by modifying genes encoding for growth factors or cytokines. The majority of gene delivery systems are based on viral transfection, naked DNA application, high pressure injection, or liposomal vectors. Recently, the combination of gene and stem cell therapy has emerged as a

promising approach for treatment of chronic and acute wounds [60].

In the future combinations of such novel approaches should have beneficial effects on outcome in the management of adult burn patients.

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Correspondence: P. Dziewulski FFICM FRCS FRCS(Plast), St Andrews Centre for Plastic Surgery and Burns, Chelmsford, Essex, CM1 7ET, UK, E-mail: peter.dziewulski@meht.nhs.uk