Early surgical excision and grafting of burns including tangential excision.

Early excision and grafting of burns with the advent of infection control, has become a most important part of any successful therapy in burn management. By this technique, an open wound is primarily closed, and thus circumvents the possibility of infection. There is less discomfort, more rapid restoration of function, quicker discharge from hospital and earlier rehabilitation. Metabolic needs are lessened and with less scar, the cosmetic result is improved. Excision is made between the third and fifth day postburn if possible, but more delay may be necessary to determine which burns are superficial and able to spontaneously heal. No area greater than 10% of body surface area is excised and grafted at one operative session and for large burns staged excisions are necessary. A limitation of 1 1/2 hours on the operation is made so as to control shock and hypothermia and to assure a quick recovery with early re-establishment of nutrition. Ketamine is the common anaesthetic employed and viable fat is preferred as the surface on which to graft. Tangential excision is a complementary form of early excision grafting to a specific depth, and may be used alone or in conjunction with other techniques. It is of value in selected burns of the deep partial skin loss variety, especially scalds, which predominate in children. Several slices of necrotic skin are taken until a punctate bleeding surface is reached in the deep dermis and a thin to moderate thickness allograft is immediately applied. The conservation of the deep dermis limits the area to be grafted, with the likelihood of less scar formation and a resultant graft of improved texture.