Early excision and skin grafting in burns by Dr. Sunil Keswani, National Burns Centre, Airoli

DR SUNIL KESWANIPlastic SurgeonNATIONAL BURNS CENTRE,Mumbai

Dr. Sunil Keswani, National Burns Centre, www.burns-india.com,

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Always early excision if patient comes early enough and facilities exist

Early enough is upto 72 hrs postburn Early excision decreases the chances of

Sepsis and facilitates early moblisation and better and more predictable functional recovery.

Delayed excision is generally at 3 weeks or later


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Within the first 3-5days After 5 days chances of Sepsis higher

and bleeding more 15% of BSA is excised at a time Coverage of excised area by Meshed

Homograft is mandatory


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Areas easy and quick to excise: trunk and legs

Joints and throats Hands and face


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Blood Loss Clear pre-operative plan Excision prior to wound hyperemia Elevation of extremities Tourniquet control Dilute Epinephrine tumescent fluid Epinephrine soaked sponges


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Procedure (En Bloc) For deeper burns Skin and fat excised in one session Less time consuming Excision down to the natural

cleavage plane Down to fat or Fascia


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Classic benefits of allograft as a physiologic and mechanical barrier:

• Reduction in water, electrolyte and protein loss

• Reduction in energy requirements secondary to the attainment of a closed wound

• Reduction in wound infection rates• Reduction in pain• Conservation of autografts• Improved general welfare and

psychological outlook of the patient


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Reduction in the number of bacteria under a biological dressing

Phagocytes within a wound use the fibrin network established between the allograft and the wound to trap and phagocytose bacteria without the production of opsonins or antibody

The effects of allografts in reducing bacteria and promoting healing have proven beneficial


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Materials that are applied for short periods then removed, to stimulate autologous healing

Cell free material that encourage colonization by autologous cells, to stimulate new skin formation

Cell containing skin substitutes: to provide immediate functional replacement


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Most widely accepted synthetic skin substitute

Bilaminar structure The median ‘take’ is 85% Two-stage procedure, with a minimum

interval of 3 weeks between the application of the Integra and the split-skin grafting

Relatively expensive


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Grown in vitro and then applied to wounds

Take of cultured epithelial autografts depends on the wound bed

Expensive Skilled labour and quality control, 3–5 weeks to produce 1.8m2 confluent

sheets of cells from a 2 cm2 biopsy Fragile sheets Blistering, infection, and contractures.


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Suggested Clinical Indications for CAE burn injuries >90% broad 70-90% more limited <70% no clear indication


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Acute burns always meshed or meek micrografting for better takes

Reconstructive procedures like overgrafting and release of contractures always sheet grafting for better cosmesis

Meek micrografting gives wider coverage and more predictable takes than mesh grafting but more expensive


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POST-PHYSICAL REHABILITATION OUTCOME


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Pre-Op wound

Application of Homograft Day 3

Complete healing Day 21


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022 2779 3333

www.burns-india.com

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Early excision and skin grafting in burns by Dr. Sunil Keswani, National Burns Centre, Airoli