to full-thickness skin grafting (FTSG) to optimize color match and minimize contracture.77 If the cheeks

or periorbital regions are involved, (FTSG) should be placed prior to the development of ectropion

which can be extremely difficult to treat. The abdomen can offer a site for large full-thickness harvest

using an abdominoplasty incision (Fig. 12-6). Full-thickness grafts, nonetheless, are limited by increased

donor site morbidity due to the need to obtain both the epidermis and dermis and also require closing

the tissues primarily to avoid additional wounds. There is also more difficulty with successful and

complete healing of the graft given that a more robust blood supply within the wound bed is necessary

to optimize take of this thicker piece of tissue. Both full- and split-thickness grafts can be meshed to

increase the surface area that may be covered. Commonly performed in a 1:1 or 1:1.5 ratio, meshing

also allows for fluid egress, which minimizes the risk of fluid accumulation beneath the graft, a common

cause of skin graft failure. Meshing should not be performed over cosmetically sensitive areas given

that the meshed pattern will be quite apparent even after complete healing has been achieved. Both

types of skin grafts should be bolstered once placed to minimize shear, improve contact, and allow for

imbibition and inosculation.

Figure 12-5. Sheet grafting of full-thickness hand burns. In general meshed grafts should be avoided on the hands and across

important joints to avoid scar contracture. (Left) Preop photo. (Middle) Intraop photo. (Right) 1-month postop photo.

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Figure 12-6. Use of full-thickness skin graft to prevent facial ectropion. Full-thickness graft harvested from the abdomen. (Left

column) Intraop photos. (Middle figures) Intraop donor site photos. (Right column) Postop 2-week photo.

When burn injuries lead to large regions of exposed tendons, especially in the distal 1/3 of the lower

extremity, free tissue transfer is often required (Fig. 12-7). It is necessary to ensure all dead tissue is

debrided prior to coverage with a free flap to mitigate infection and flap failure. Additionally, if the

patient is elderly or has vascular insufficiency, a preoperative computed tomography angiogram should

be obtained.

In larger burn wounds, patients may not have an adequate surface area available for donor sites. In

such cases, allograft can be used for initial coverage. This homograft will serve as a temporary coverage

and its take will ensure that the initial excision was performed at the correct depth. Allografts will

eventually be rejected as the body recognizes the newly engrafted skin as foreign material after 10 to

13 days. The process is initiated by the placement of the allografts, which is associated with an

inflammatory process, leading to the activation of the innate immune response. Donor dendritic cells

migrate from the graft to the recipient’s secondary lymphoid organs where they present donor antigens

and elicit an adaptive immune response. This response results in activated effector T cells from the

donor leaving the secondary lymphoid organs and infiltrating the graft where they mediate the rejection

of the allograft.78

If insufficient autograft exists even after temporary allograft, the surgeon should consider use of

cultured epidermal autografts. Cultured epidermal autografts utilize the ability to grow keratinocytes in

vitro to generate cohesive sheets of stratified epithelium, which maintain the characteristics of authentic

epidermis. This technique was developed by Rheinwald and Green in 1975.79 A 3- to 4-cm2 sample is

taken usually from the axilla or pubic area at the time of initial debridement, and epidermal cells are

isolated from the small skin biopsy and plated onto a layer of feeder cells that act as a supporting

“feeder layer.”80 The feeder layer supports optimal clonal expansion of proliferative epithelial cells and

promotes keratinocyte growth. Under optimal growth conditions, keratinocytes initiate growing

colonies and after 3 to 4 weeks, the cultured epidermal autograft sheets are 8 to 10 cells thick.81,82

These constructs require advanced planning as it takes at least 3 to 4 weeks to develop. Additionally,

risks and benefits should be discussed with the family and patient as there is a high percentage of graft

loss due to fragility. Furthermore, case reports of squamous cell cancer developing from cultured

epidermal autograft sites exist.

Order of Coverage

6 The first operations performed in large burn patients set the stage for how quickly a patient will

recover. The first priority should be to excise all eschar and achieve coverage, with autograft if

available or with allograft if not available. In patients with large TBSA burns, it is crucial to get the

back excised and covered first as delay of this step will make it difficult to have a patient stable enough

to tolerate a prone position. Additional strategies to improve coverage of the back include the use of

autograft meshed 3:1 covered with allograft meshed 2:1 and a secure bolster placed over top. This

minimizes sheer and loss of the autograft. Early coverage of the back and avoidance of prone

positioning may also mitigate the need to perform an early tracheostomy. Once the posterior areas of

the patient are excised and covered, then attention can be turned to the anterior regions and the

extremities.

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Figure 12-7. Use of free anterolateral thigh flap for reconstruction of lateral full-thickness ankle burn with exposed tendon. Top

left shows initial injury. Middle left shows ALT flap inset. Bottom left shows final ALT placement. Top right shows ALT donor site

intra op. Middle left shows donor site 1 week postop. Bottom right shows ALT 1 week postop.

Extremity Treatment

Burns of the hands and feet often require a multidisciplinary approach with involvement of therapists,

hand and plastic surgeons. Early evaluation must verify adequate perfusion. Extremity elevation

benefits hand burns by limiting edema and active range of motion is necessary to maintain function.

Splinting should put the axilla at 90 degrees, elbow in extension and hand in intrinsic plus with the

metacarpophalangeal joints at 70 to 90 degrees and the interphalangeal joint and the wrist in 20- to 30-

degree extension.

Palmar hand or plantar foot burns occur on specialized skin and are composed of a thicker dermal

layer and thus should be managed conservatively. If after 3 to 4 weeks no healing has occurred, full

thickness burns should be considered. Small palmar digit burns can be treated with a full thickness

hyperthenar graft.

Though the hands and feet are important to excise and cover early, these areas require the use of

sheet or 1:1 meshed grafts. These areas should not delay the coverage of large areas such as the back

which can use widely meshed grafts. More important, for the digits, is the use of early K-wire fixation

in the intrinsic plus position in deep burns to the fingers. K-wires should be placed in the fingers to keep

them in the intrinsic plus position: MC flexed at 70 to 90 degrees, wrist 20 to 30 degrees, IP joints in

full extension, and thumb kept abducted and slightly opposed. This will help prevent severe joint flexion

contractures which can lead to the loss of digits if straightened in a delayed fashion.

Genital Burns

Genital burns should be investigated for abuse in children. Burned foreskin must be reduced to a normal

position to avoid paraphimosis. Penile and scrotal burns will often heal without excision and grafting.

Bladder catheterization and urethral stenting is not required for genital burns and increase the risk of

infection.

Skin Alternatives

Integra is a newer alternative for temporary coverage and creation of a neodermis in a wound after

debridement. Composed of bovine collagen and silicone film, this construct is designed to mimic the

epidermis and dermis of the missing tissue.75,83 Its structure allows for the growth of healthy

granulation tissue into a wound bed to optimize the wound niche to promote greater and healthier take

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of the skin graft that will eventually be placed over the site of injury. This is especially important over

areas of function, such as the hand, which has the potential for significant debility if scar or graft

contracture occurs over the traumatized site. Integra is also important for areas that do not have enough

viable or vascularized tissue to support a skin graft (Fig. 12-3). Integra, however, often fails in burn

patients due to infection and requires constant soaks with Sulfamylon. Additionally, clinicians should

examine the Integra frequently and remove any areas of silicone under which there is concern for

infection.

Figure 12-8. Xenograft treatment of superficial partial-thickness burn to avoid use of STSG and to improve pain. (Top, left)

Intraop photos of superficial partial-thickness burn. (Top, right and bottom, left) Placement of xenograft over burn using

interrupted absorbably sutures. (Bottom, right) 1-month postop from xenograft placement.

Porcine xenografts are an alternative to dressing changes alone in superficial partial-thickness burn

wounds. In wounds that are likely to heal by themselves taking the patient to the operating room,

performing a good debridement under anesthetic, and placement of xenograft to the burn wound can be

beneficial (Fig. 12-8). The xenograft can minimize pain, improve wound healing, and de-escalate the

complexity of dressing changes. This benefit is greatest in children or patients with tolerance to narcotic

pain medications due to excessive pharmacologic supplementation prior to becoming injured.

PAIN CONTROL

Acute Pain

Burn injuries are among the most painful traumatic injuries sustained given their extensive nature.

Thermal injury to the overlying epidermis leads to exposed nerve endings which are sensitive to

stimulation. Thus, superficial partial-thickness burn injuries often cause the most pain to the patient.

Deeper partial-thickness and full-thickness injuries may not cause as much pain to palpation; however,

these regions are still painful due to the inflammatory response. Given the multifactorial nature of burn

pain, elimination of pain in burn patients is not possible. Outcomes are often improved if a dedicated

physician with expertise in pain management is part of the burn team. When establishing a pain

regimen, the physician should focus on treating acute as well as chronic pain. A successful regimen often

includes the use of short- to intermediate-acting narcotics to treat acute pain as well as a long-acting

narcotic such as methadone for chronic pain. Procedural pain during dressing changes can be treated

with short-acting narcotics. Some patients will also benefit from Neurontin to alleviate neurologic pain.

Additional studies are underway to investigate the use of Seroquel for patients with a large anxiety

component associated with their pain. Balancing of narcotic dosing over time is essential to preserve

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their acute pain relief effect and to avoid situations in which tolerance renders all available agents and

doses ineffective.

Chronic Pain and Substance Abuse

The burn patient population that is admitted with underlying substance abuse and alcohol dependency is

a particular challenge for the burn team to successfully treat with regard to pain relief. In such

circumstances, the team should have high vigilance for symptoms of drug or alcohol withdrawal. New

studies are investigating prophylactic treatment with barbiturates to prevent alcohol withdrawal rather

than currently used strategies which are largely reactionary and treat withdrawal after symptoms occur.

Involvement of psychiatrist or pain specialist in the prescription of these drugs is beneficial. Methadone

can also serve as a helpful adjunct for patients with chronic pain given its decreased addictive potential

relative to other narcotics.

INFECTIONS

Wound Infections

Burn wound sepsis is a severe sequelae of burn injuries caused by colonization of the damaged skin and

soft tissues with infectious bacteria or fungi. The most common organisms are Staphylococcus aureus,

Streptococcus pneumoniae, and Pseudomonas aeruginosa. Despite the morbidity of this complication, its

incidence has decreased dramatically with the use of early excision and grafting and appropriate topical

antibiotics therapy. If burn wound infection is suspected, wound dressings should be taken down and a

quantitative culture should be obtained. A bacterial count of greater than or equal to 105 colonyforming units bacteria/gram of tissue is considered significant infection, though the data from which

this number was derived date back to the 1960s. General critical care infection protocols should be

followed with burn wound debridement if the patient does not yet have skin grafts placed. If adequate

excision has been performed and the patient already has skin grafts placed, then antibiotic soaks or

cream dressing changes and IV antibiotics will often help combat infection. Quantitative cultures should

be obtained every 3 to 4 days when treating burn wound infection to gauge progress and allow for

escalation or de-escalation of treatment.

Vascular Catheter–Related Infections

Central venous access should be obtained using sterile technique and antibiotic-impregnated catheters as

these have proven efficacious in the general critical care population84 (ref is Pronovost/Keystone).

Additionally, central venous catheters should be placed in nonburned areas if possible. Routine changing

of catheter after a specific time period has not been shown to improve outcomes. However, close

attention should be paid to catheters in place for over 7 days, especially in burn areas if the patient is

febrile and has signs of systemic infection. If a catheter-related infection is suspected, two peripheral

blood cultures should be drawn. A culture specifically from the catheter does not improve diagnosis or

outcomes. Despite the increased use of PICC lines, these catheters have equal if not increased risk of

infection relative to central venous catheters.

Pneumonia

Along with increased survival of burn patients comes increased time burn patients are on the mechanical

ventilator. Increased incidence of pneumonia is seen with inhalation injuries and prolonged intubation

and mechanical ventilation. As in other critical care populations, an emphasis should be placed on daily

awakening and extubation/spontaneous breathing trials. Additionally, all patients on the ventilator

should have their head of bed elevated greater than 30 degrees and daily chlorhexidine mouthwashes

may be beneficial. If a pulmonary infection is suspected, a CXR should be performed and a quantitative

culture specimen should be obtained from the bronchial tree. A quantitative result greater than 103 is

considered positive and should be treated.

Deep Vein Thrombosis

The dangers and need for prophylaxis in general surgical and burn patients have been highlighted in

recent studies. Burn patients have increased risk with increased number of operations, pneumonia, and

central venous access. All inpatients should receive prophylaxis with heparin 5,000 U three times a day

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