Early burn excision and grafting.

The current state of knowledge and experience with early burn wound closure leads to some conclusions that are proved and others that are suggested. The issues that are proved include the following: Small (less than 20 per cent TBSA) full-thickness burns and indeterminate (deep partial-thickness versus full-thickness) burns, if treated by an experienced surgeon, can be excised safely and grafted with a decrease in hospital stay, cost to the patient, and time away from work or school. Early excision and grafting dramatically decreases the number of painful ward debridements required by all patients. Patients with burns between 20 and 40 per cent TBSA appear to have fewer infectious wound complications and a shortened hospital stay if treated with early excision and grafting. In addition to the above conclusions, about which there is little disagreement, there are other suggestive data and clinical impressions that do not yet have "hard data" to support them. These issues include the following: Scarring is less in wounds closed early, leading to better appearance and the need for fewer reconstructive procedures. There presently is not a good measure of "cosmetic appearance," and comparative studies await an acceptable scale to measure results. Mortality from wound infection is less in patients with major burns. Because wounds exceeding the donor sites cannot be closed permanently and completely until donor sites can be reharvested, proof will come only when a durable permanent cover can be applied in a timely fashion. Data now suggest that mortality has decreased, but none of the studies has been conclusive. Mortality from other complications of major burns may decrease with early excision and grafting. Decreasing stress, hypermetabolism, and decreasing the overall bacterial load of such patients enables them to resist other complications better. The only present data supporting this conclusion, however, come from animal studies. The current state of the art suggests that small, deep burns can be excised and grafted by general or plastic surgeons in community hospitals as long as they are interested in the procedure and the hospital has the proper support facilities. Burns of cosmetically or functionally important areas (face, hands, feet, and joints) should be excised by someone with a special interest in burns, and burns in excess of 10 per cent TBSA should be excised only in facilities with excellent support facilities, including an experienced anesthesiologist, trained nursing personnel, good critical-care facilities, and a safe blood bank.