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15 MANAGEMENT OF THE BURN WOUND 1

15 MANAGEMENT OF THE BURN

WOUND
Jose P. Sterling, MD, David M. Heimbach, MD, FACS, and Nicole S. Gibran, MD, FACS

Advances in resuscitation and critical care have significantly

improved survival after thermal injury. Ultimately, survival
remains contingent on effective wound management and
complete wound closure. Current approaches to burn management are based on an understanding of the biology and
physiology of human skin and the pathophysiology of the
burn wound.
Anatomic and Physiologic Considerations
biology of the skin
The skin is a complex organ composed of two distinct
layers, the epidermis and the dermis; these layers are integrated by a structure known as the basement membrane
zone (BMZ) [see Figure 1]. It provides containment, structure,
protection, homeostasis, excretion, temperature regulation,
biosynthesis, sensory perception, and appearance.
The epidermis is the outer layer and acts as the barrier
between body tissues and the environment. This layer protects against infection, ultraviolet light, and evaporation of
fluids and provides thermal regulation. The epidermis is
derived from fetal ectoderm and, thus, like other ectodermal
derivatives, is capable of regeneration. Repair of epidermal
wounds is achieved through regeneration of epidermal cells
both from the perimeter of the wound and from the adnexal
structures of the epidermis (i.e., hair follicles, sweat glands,
and sebaceous glands).1 Accordingly, pure epidermal injuries
heal without scarring.
The principal cell of the epidermis is the keratinocyte.
These cells are arranged into five progressively differentiated
layers, or strata: the stratum basale, the stratum spinosum,
the stratum granulosum, the stratum lucidum, and the stratum corneum. The outermost of these layersthe relatively
impermeable stratum corneumprovides the barrier mechanism that protects the underlying tissues. These layers are
derived from continued cell division and maturation of the
basal keratinocyte stem cells at the stratum basale, the deepest
level of the epidermis.
Besides keratinocytes, the epidermis contains cells from
other embryologic layers that carry out specific functions.
These cells include melanocytes and Langerhans and Merkel
cells. Melanocytes, derived from fetal neuroectoderm, migrate
to the ectoderm during normal embryogenesis and populate
the interfollicular stratum basale and hair follicles. These
send dendritic processes between the basal cells to the epidermis, anchoring them to the keratinocytes. Through these
dendritic processes, melanosomes are transferred via phagocytosis to the adjacent keratinocytes. The melanosomes
synthesize the pigment melanin through the action of the

enzyme tyrosinase. Melanin provides the skin with its pigment and absorbs harmful ultraviolet radiation. Melanocytes
are terminally differentiated cells without reproductive ability.2 Hence, deep dermal injuries often lead to cutaneous
hypopigmentation.
Langerhans cells, derived from bone marrow cells, play a
critical role in the immune function of the skin. These cells
recognize, phagocytize, process, present foreign antigens,
and, through their expression of class II antigens, initiate the
rejection process in skin transplantation.3 Merkel cells are
neuroendocrine cells that reside near hair follicles and nerve
endings. These cells are transducers of fine touch. Their
embryonic origin and homeostasis are a source of great
debate.4 However, their presence in the hand and feet must
be considered when deciding whether to excise and graft the
volar and plantar surfaces.
In contrast to the epidermis, the dermis is a complex network comprising cellular and acellular components. This
layer provides skin with its durability and elasticity. Structurally, the dermis consists of two sublayers, a superficial one
(the papillary dermis) and a deeper one (the reticular dermis).
Collagen is the major structural matrix molecule, constituting
approximately 70% of the skins dry weight. Elastic fibers
account for approximately 2% of the skins dry weight and
play an important role in maintaining the integrity of the skin
after mechanical perturbation. Glycosaminoglycans (GAGs)
and adhesion molecules are the third major extracellular
components of the dermis. These molecules help regulate
intracellular and extracellular events by binding to, releasing,
and neutralizing cytokines and growth factors.4,5 Adhesion
molecules are crucial for cellular migration and chemotaxis in
and out of the wound.
The fibroblast is the principal cell of the dermis and is
responsible for synthesis and degradation of fibrous and
elastic dermal proteins. The dermis also contains various
bone marrowderived inflammatory cells and other poorly
understood mesenchymal stem cells, mast cells, and cells
associated with vascular, lymphatic, and nervous tissue.
The BMZ is a complex region of the extracellular matrix
connecting the basal cells of the epidermis with the papillary
dermis. At the light microscopic level, the dermal-epidermal
junction consists of protrusions of dermal connective tissue
known as dermal papillae, which interdigitate with epidermal
projections known as rete ridges. The structure of the BMZ
is best appreciated on electron microscopy, where it appears
as a trilaminar zone consisting of a central electron-dense
region (the lamina densa) flanked on both sides by regions of
lower electron density [see Figure 2]. Within the basal cells of
the epidermis are multiple sites of attachment to the basal
lamina, which are known as hemidesmosomes. On the dermal

DOI 10.2310/7800.S07C15
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ACS Surgery: Principles and Practice

15 MANAGEMENT OF THE BURN WOUND 2
side of the basal lamina are numerous anchoring fibrils, which
reach from the lamina into the connective tissue of the dermis.
The BMZ plays a significant role in burn wound healing:
epithelialized wounds undergo blistering until the anchoring
structures of the BMZ mature and provide protection from
shearing.6
pathophysiology of thermal injury
Jacksons 1953 classification of burn wounds remains the
foundation of our understanding of the pathophysiology
of thermal injury to the skin.7 In this classification, there
are three zones of tissue injury resulting from a burn [see
Figure 3]. The central, most severely damaged area is called
the zone of coagulation because the cells in this area are coagulated or necrotic. Tissue in this zone must be dbrided. The
zone of coagulation is surrounded by the zone of stasis, an
area characterized by vasoconstriction and ischemia. Tissue
in this zone is initially viable; however, it may convert to
coagulation as a consequence of the development of edema,
infection, and decreased perfusion. With good wound perfusion, tissue in the zone of stasis generally remains viable.
Surrounding the zone of stasis is the zone of hyperemia, an
area characterized by vasodilation resulting from the release
of inflammatory mediators from resident cutaneous cells.
Tissue in this zone typically remains viable.

Figure 1 Cross-sectional diagram shows the two distinct

layers of the skinthe epidermis and the dermis (papillary
and reticular)and the underlying subcutaneous fat.

Figure 2 The basement membrane zone (BMZ) integrates

the epidermis with the underlying dermis. On electron
microscopy, the BMZ has three layers: a central
electron-dense region known as the lamina densa and two
regions of lower electron density to either side of this central
region.

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Clinical Evaluation and Initial Care of Burn Wound

After admission to the burn center, the burn wound is
cleaned with soap and water, blisters and debris are removed,
and the extent and depth of the wound are assessed. Management of tar burns warrants special mention. When tar that
has been heated to maintain a liquid form comes into contact
with skin, it can transfer sufficient energy to cause a significant burn injury. As the tar cools on the skin, it solidifies,
thereby becoming difficult to remove. Solvents such as petrolatum, petrolatum-based ointments, lanolin, and Medi-Sol
(Orange-Sol, Inc., Gilbert, Arizona) are useful for tar removal.
For optimal effect, 10 to 15 minutes should be allowed after

Figure 3 A burn wound is characterized by three zones of

injury: A represents the zone of coagulation, B the zone of
stasis, and C the zone of hyperemia.

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pink, moist, and painful. They usually heal within 2 to 3
weeks, without scarring or functional impairment. Deep
partial-thickness wounds extend into the reticular layer of the
dermis. They are typically a mottled pink-and-white, dry, and
variably painful. In some cases, they may be difficult to distinguish from full-thickness burns. Deep partial-thickness
burn wounds, if they do not become infected, typically heal
in 3 to 8 weeks, with severe scarring, contraction, and loss of
function. Therefore, if a partial-thickness burn has not healed
by 3 weeks, surgical excision and skin grafting may be
required.
Full-thickness burn wounds extend through the entire
dermis and into the subcutaneous tissue. These burns are
typically white or black, dry, and painless [see Figure 5]. Some
full-thickness burns appear red, but they can be distinguished
from superficial burns because they are not moist and do not
blanch with pressure. Because all skin appendages are burned
away, full-thickness burns can heal only by contraction or
migration of keratinocytes from the periphery of the wound.
Accordingly, all full-thickness burns, unless they are quite
small (e.g., the size of a quarter or smaller), must be treated
with excision and grafting.
As a rule, both superficial and full-thickness burns are
easily recognized, and treatment decisions are relatively
straightforward. It is frequently difficult, however, to determine the ultimate fate of intermediate partial-thickness burns
soon after injury. For this reason, these wounds are often
referred to as indeterminate-thickness wounds. Over the
course of the first several postburn days, it usually becomes
easier to determine which indeterminate-thickness wounds
are likely to heal in a timely manner, without the need for
grafting.
Various techniques for assisting the assessment of burn
depth have been described, including the use of vital dyes,
laser flowmetry, thermography, and magnetic resonance
imaging.8 However, none of these adjuncts have been shown
to replace the clinical evaluation of an experienced burn care
provider.

solvent application before removal of the tar is attempted.

Repeat applications may be necessary for complete removal.
assessment of burn depth
Thermal injury can damage the epidermis alone, the
epidermis along with a portion of the dermis, or the entire
skin and can even extend into the underlying subcutaneous
tissue. The depth of the injury affects the subsequent healing
of the wound; thus, assessment of burn wound depth is
important for selection of wound dressings and, ultimately,
for determination of the need for surgery [see Table 1].
Superficial burns involve only the epidermis. They typically
are erythematous and painful, much as a sunburn would be.
Most such burns heal within 3 to 4 days, without scarring.
The usual treatment is a soothing moisturizing lotion (e.g.,
one containing aloe vera), which both optimizes the rate of
epithelialization and provides comfort to the patient.
Partial-thickness burns extend through the epidermis and
into the papillary dermis. Blistering is their hallmark [see
Figure 4]. These burns can be further categorized as superficial or deep. Superficial partial-thickness burns are typically

Table 1 Overview of Burn Wound Management

Burn Wound
Type

Clinical
Features

Management

Superficial

Erythematous,
painful

Soothing, moisturizing
lotions (i.e., aloe)

Partial
thickness

Blistered, pink,
moist, painful

Silver sulfadiazine; greasy

gauze once epithelial
buds are present

Deep partial
thickness

Dry, mottled
pink-and-white,
less painful

Silver sulfadiazine
dressings daily; surgical
excision and grafting if
not going to heal within
3 wk

Full thickness

Dry, leathery,
black or white,
painless

Silver sulfadiazine; early

excision and skin
grafting

Figure 4 Shown at left is a shallow scald burn with the pink, moist appearance typical of a superficial partial-thickness burn
wound. Such injuries typically heal without the need for excision and grafting. A superficial partial-thickness burn (a), which
involves only the papillary dermis, is visually distinct from a deep partial-thickness burn (b), which is mottled in appearance,
extends into the reticular dermis, and is more likely to require excision and grafting.

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Figure 5 Shown is a full-thickness flame burn with a

characteristic brown, leathery appearance. Such wounds
require excision and subsequent skin grafting.

determination of need for escharotomy

Burn wound eschar consists of dead skin, has the consistency of leather, and may restrict limb perfusion by creating
a nonelastic exoskeleton. A key issue in assessing burn wounds
is whether escharotomies are necessary. In general, escharotomies are required only for circumferential full-thickness
extremity burns in which distal perfusion has been compromised or for chest burns in which eschar poses an external
mechanical barrier to respiration. Escharotomies can be performed at the bedside with either a scalpel or an electrocautery. They should extend through the eschar only, not through
the muscle fascia. Adequate release is signaled by separation
of the eschar, improved distal perfusion, and, sometimes, a
popping sound. Because an escharotomy is a superficial incision through dead tissue, only minimal doses of analgesics
and anxiolytics are required.
daily burn wound care
The use of hydrotherapy tanks, previously a standard
component of burn unit wound care, has fallen from favor
somewhat because of the risks of cross-contamination between
one burn wound area and another. It is preferable to place
the patient on a shower table, which is inclined so that water
runs off the wounds and into a drain [see Figure 6]. Smaller
wounds can often be managed with bedside wound care after
a shower. Increasingly, partial-thickness burns are treated
with biosynthetic and or silver-impregnated materials that do
not require daily wound care.9 Washing with tap water and
regular soap suffices for daily burn wound cleansing. It is
important to be cognizant of the need to provide adequate
sedation and analgesia while performing daily wound care
a particularly challenging task with infants and elderly
patients.

Figure 6 Shower tables are generally preferred to Hubbard

tanks for burn wound care. A clean plastic drape can be used
to cover the shower table during patient care.

against environmental flora. Burn dressings also protect

against evaporative heat loss. The ideal burn dressing would
be inexpensive and comfortable and would not require frequent changing. Daily dressing changes allow the burn care
provider not only to apply clean dressings but also to clean
the wounds and dbride fragments of separated eschar and
devitalized tissue.
Numerous topical agents and dressings are available for use
in burn patients; we limit our discussion to the ones that are
most commonly employed and have proved most effective.
Selection of an appropriate dressing for a given wound is
governed by the specific goals of management. With purely
superficial wounds, the goal is to create a moist environment
that will optimize epithelialization. Typically, this is achieved
by applying ointments or lotions. With partial-thickness and
full-thickness wounds, however, it is necessary to include
agents that protect against microbial colonization (see below).
Once a partial-thickness burn demonstrates evidence of epithelialization, dressings should be changed to a regimen that
facilitates healing (e.g., greasy gauze with ointment).
antimicrobial agents

Topical Burn Wound Treatment

general principles
Because thermal injury disrupts the protective barrier function of the skin, dressings are needed to protect the body

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It must be emphasized that systemic antibiotic prophylaxis

plays no role in the management of acute burn wounds and
provides no protection against microbial colonization of burn
eschar10; in fact, use of prophylactic antibiotics in burn
patients increases the risk that opportunistic infections will

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develop. Because eschar has no microcirculation, it is impossible for systemically administered antibiotics to reach the
eschar surface, where colonization occurs. Therefore, topical
preparations, which are capable of supplying high concentrations of antimicrobial agents at the wound surface, must be
used. In the early postburn period, the dominant colonizing
organisms are staphylococci and streptococcitypical skin
flora. Over time, however, the burn wound becomes
colonized with gram-negative organisms.11 Thus, topical
antimicrobial agents used in early burn care should have
broad-spectrum coverage to minimize colonization of the
wound, but they need not be able to penetrate the burn
eschar deeply.
Of the antimicrobial agents used in this setting [see Table 2],
silver sulfadiazine is the one most commonly employed for
partial-thickness and full-thickness burns. Silver sulfadiazine
is soothing on application and is active against a broad spectrum of microorganisms. Because it does not penetrate eschar,
very little is systemically absorbed; therefore, it is ineffective
against already established burn wound infections. Wounds
treated with silver sulfadiazine may form a tenacious yellowgray pseudoeschar, which can be mistaken for true eschar.
This pseudoeschar develops when silver sulfadiazine combines with the wound exudates; it can be gently dbrided
during daily wound care. It has been suggested that silver
sulfadiazine may be responsible for the leukopenia that
sometimes develops during the first week after a major burn.
This attribution may not be entirely accurate, however, given
that this leukopenia may also develop in patients treated
with silver nitrate. It is possible that the leukopenia results
not from either agent but from the margination of neutrophils
secondary to the pathophysiology of the burn injury itself.
In any case, the leukopenia is typically self-limited and
necessitates no change in therapy. Patients with a history of
sulfa allergy typically do not have adverse reactions to silver
sulfadiazine; however, if there is concern about a possible
reaction, a test patch can be applied to a small area of the
wound. If the patient is allergic, silver sulfadiazine will cause
pain on application or, in some cases, a rash.

Mafenide acetate is also commonly used in the management of burn wounds. It provides excellent coverage against
gram-negative organisms, but it is not as active against staphylococci and has no antifungal activity. Unlike silver sulfadiazine, mafenide penetrates eschar very well, and this ability
makes it effective in treating as well as preventing burn wound
infections. Mafenide does, however, have some drawbacks.
Because it is a potent carbonic anhydrase inhibitor, regular
use and the consequent ongoing systemic absorption can
lead to metabolic acidosis. In addition, because it is so well
absorbed, twice-daily administration is necessary. Finally,
topical application of mafenide, particularly to partialthickness burns, is painful, which limits its utility in the
routine management of burn wounds. Mafenide is frequently
used on the ears and the nose because of its ability to
penetrate eschar and protect against suppurative chondritis;
however, silver sulfadiazine appears to be equally effective in
this setting.12 Mafenide is available both as a cream and as a
solution. The solution is useful as a topical agent for skin
grafts when the wound bed is considered likely to benefit
from postoperative antimicrobial treatment.
Silver nitrate provides broad-spectrum antimicrobial
coverage, including good activity against staphylococci and
gram-negative organisms (e.g., Pseudomonas). It is relatively
painless on administration and must be reapplied every 4
hours to keep the dressings moist. It does not readily penetrate eschar. Silver nitrate is used in the form of a 0.5%
solution, which is bacteriostatic but is not toxic to epithelial
cells. The hypotonic formulation (it is reconstituted in water)
can cause osmolar dilution, resulting in hyponatremia and
hypochloremia. Therefore, careful electrolyte monitoring and
diligent replacement are necessary. In rare cases, use of silver
nitrate solution can also lead to methemoglobinemia; if this
condition is detected, administration of silver nitrate should
be discontinued. A principal disadvantage of silver nitrate
solution is that it stains everything it touches black.
Newer silver-containing dressings are now manufactured,
improving care by decreasing the need for daily wound care.
Some dressings contain nanocrystalline silver embedded on a
high-density polyethylene mesh (Acticoat, Smith & Nephew,

Table 2 Topical Antimicrobial Agents Used in Burn Care

Agent

Antimicrobial Coverage

Advantages

Disadvantages/Precautions

Bacitracin

Gram-positive bacterial

Soothes and moisturizes; good for

facial care and epithelializing
wounds

Not appropriate for deeper wounds

Mafenide

Broad-spectrum antibacterial;
anticlostridial

Penetrates eschar well; available as

solution or cream

Painful on application; causes metabolic

acidosis (via carbonic anhydrase inhibition)

Mupirocin

Anti-MRSA

Effective against MRSA

Narrow (poor gram-negative) antimicrobial

coverage

Nystatin

Antifungal (Candida)

Provides fungal prophylaxis with

swish-and-swallow solution

May interfere with activity of mafenide

Silver nitrate

Broad-spectrum antibacterial

Effective for both prophylaxis and

treatment of wound infection

Penetrates eschar poorly; causes

hyponatremia; stains linen and dressings;
induces methemoglobinemia

Silver sulfadiazine

Broad-spectrum antibacterial;
antipseudomonal

Soothes on application and causes

no pain

Penetrates eschar poorly; causes leukopenia

MRSA = methicillin-resistant Staphylococcus aureus.

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London, England), embedded in hydrofibers (Aquacel AG,
ConvaTec Bristol-Meyers Squibb Company, Skillman, New
Jersey), or attached to a soft silicone dressing (Mepilex Ag,
Mlnlycke Health Care US, LLC, Norcross, Georgia). It is
speculated that the nanocrystalline silver provides a sustained
release of elemental silver, contributing to aerobic, anaerobic,
gram-positive and gram-negative antimicrobial activity.13
Acticoat has been successfully used for coverage of partialthickness burns, as well as for coverage of donor sites and
meshed skin grafts.14 With burn wounds, the Acticoat dressing is typically changed every 3 days. The reduced frequency
of dressing changes simplifies burn care somewhat but can
hinder evaluation of evolving partial-thickness burns. With
donor sites, Acticoat can be left in place until the underlying
partial-thickness wound heals. Typically, an adhesive tape
such as Hypafix (Smith & Nephew) is used to secure the
dressing to the donor site for 7 days. Once the tape has been
removed, the Acticoat usually is sufficiently adherent to allow
patients to shower daily and towel-dry the dressing until it
eventually peels off the healed wound. The development of
nanocrystalline silverembedded products has increased the
treatment modalities of the burn patient.
Bacitracin, neomycin, and polymyxin B have all been used
for coverage of superficial wounds in conjunction with Xeroform or petrolatum gauze to accelerate epithelialization and
minimize colonization. These ointments also are commonly
administered several times daily in the care of superficial face
burns. Mupirocin has proved effective in treating methicillinresistant Staphylococcus aureus (MRSA) colonization; however, because of the potential for the development of bacterial
resistance, it should be employed only in MRSA-positive
wounds.
Surgical Burn Wound Management
As noted [see Clinical Evaluation and Initial Care of Burn
Wound, Assessment of Burn Depth, above], superficial burns
and superficial partial-thickness burns typically heal without
any need for surgical excision and grafting. Dressing changes
and wound care can remove necrotic debris and provide an
environment conducive to healing in a timely fashion (2 to 3
weeks), with minimal scarring. For deep partial-thickness and
full-thickness burns, however, operative dbridement with
subsequent skin graft coverage is necessary. Timely removal
of eschar is critical for successful management. Surgical
excision removes necrotic tissue that serves as a nidus for
microbial proliferation and the development of burn wound
sepsis.15,16
early excision and grafting
Surgical excision of burn wounds is a concept whose
importance was not fully appreciated until the 1970s. Previously, the usual practice was to leave eschar intact over
the wound surface, the idea being that proteolytic enzymes
produced by migrating neutrophils and bacteria within the
contaminated eschar would cause a natural separation of the
eschar from the wound bed (sloughing) and that the resulting
granulating wound would serve as the bed for grafting. The
rationale for delaying surgical management was that it would
presumably allow the burn care provider time to determine
which wounds would heal spontaneously and which would
have to be covered with skin grafts. It has since become clear,

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15 MANAGEMENT OF THE BURN WOUND 6
however, that in cases of extensive burn injury, delayed management results in more extensive bacterial colonization, as
well as an increased likelihood of burn wound sepsis, multiple
organ failure, and, ultimately, death.
Early excision and skin grafting of small burn wounds were
first described by Lustgarten in 1891.17 After the Cocoanut
Grove fire in 1942, Cope and colleagues suggested that
patients treated with early excision and grafting had better
overall outcomes.18 In 1960, Jackson and colleagues reported
discouraging results with early burn wound excision,19 and it
was not until 10 years later, when Janzekovic reported good
results with surgical burn wound excision,20 that enthusiasm
for early excision was rekindled. As clinical experience with
early excision was accumulated, the benefits became clear.
Since Janzekovics report, studies have repeatedly shown
that early wound excision and closure improve survival,
reduce the infection rate, and shorten hospital stay. Other
studies have demonstrated that early removal of dead and
severely damaged tissue interrupts and attenuates the systemic inflammatory response syndrome (SIRS).15,16,2124 Early
excision of deep burn wounds also appears to decrease hypertrophic scarring. Similarly, early excision and grafting have
been shown to be beneficial for burns of indeterminate depth.
In a study of patients with burns covering less than 20% of
their total body surface area (TBSA), early excision and grafting reduced length of stay, cost of care, and time away from
work in comparison with nonoperative treatment.25
wound excision
Early staged excision, beginning as early as postburn day
3 if feasible, is now conventional treatment for major burns.
Operations are spaced 2 to 3 days apart until all eschar
is removed and full wound coverage is achieved. Dbrided
wounds can be temporarily covered with biologic dressings
or cadaveric allograft until autogenous donor sites are
available.26,27
Generally, the decision whether to perform operative
wound excision is guided by whether spontaneous wound
healing is likely to occur in a timely fashion (i.e., within 2 to
3 weeks after the burn). Burn wounds over joint surfaces,
however, should undergo excision and grafting sooner so
as to minimize healing by wound contraction, which can
ultimately lead to disabling contractures. In patients with
extensive burns, hemodynamic and pulmonary status must
be considered in deciding on the timing of operation. Any
critically ill burn patient will have some degree of respiratory
dysfunction, but the patient should at least be capable of
being safely transported from the intensive care unit to the
operating room and back. The risk of hypothermia and
the need for blood transfusion must be anticipated before
operation and clearly communicated to the anesthesiologist.
There are two main technical approaches to surgical
excision of the burn wound: fascial excision and tangential
excision. Fascial excision, as the name suggests, involves
excising the burned tissue and the underlying subcutaneous
tissue down to the muscle fascia [see Figure 7]. A major
advantage of fascial excision is that it yields an easily defined
plane that is well vascularized and therefore can readily accept
a graft. In addition, bleeding is generally easier to control at
the fascial level of dissection because the vessels are easier to
identify and coagulate. Furthermore, the entire excision can

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Figure 7 Fascial excision involves excision of the burned

skin and the underlying subcutaneous tissue down to the level
of the muscle fascia. It is typically performed with the
electrocautery. As shown (arrows), the edges should be
tacked down to minimize the ledge at the edge where normal
tissue adjoins the exposed fascia.

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15 MANAGEMENT OF THE BURN WOUND 7
to control the depth of excision. The appearance of diffuse
punctate bleeding signals that viable tissue has been reached.
The main disadvantages of tangential excision are that (1) it
may be difficult to control the diffuse bleeding from the
wound bed, and (2) it may be difficult to assess the suitability
of the underlying fat for accepting a graft.
A water jetpowered instrument (VersaJet Hydrosurgery
System, HydroCision, Andover, Massachusetts) is available
that can be used for tangential burn wound excision. This
device offers an easy and relatively precise way of excising
eschar and is particularly useful for excising nonviable tissue
from the concave surfaces of the hands and feet, as well as
the eyelids and ears.30
To minimize hematoma formation and graft loss, it is
critical that adequate hemostasis be achieved before the
placement of skin grafts, cadaveric grafts, or skin substitutes.
Telfa pads (Kendall, Mansfield, Massachusetts) soaked in an
epinephrine solution (1:10,000) are a mainstay of hemostasis,
combined with topical pressure and cauterization when necessary. A fibrinogen thrombin delivery system (Tisseel Fibrin
Sealant, Baxter, Deerfield, Illinois) is commercially available
that improves the ability to control bleeding after excision.
Regardless of which excision technique is used, bloodconserving strategies should be used routinely to minimize
transfusion requirements. These strategies include manual
pressure, use of topical epinephrine and/or fibrin sealant,
tumescence of burn wounds with vasoactive medications, and
the use of tourniquets.3133 The extremities can be suspended
from operating room ceiling hooks [see Figure 9] to provide
access to their entire circumference.

be performed with the electrocautery, and blood loss is

thereby minimized. The principal drawback of this approach
is that the excision inevitably includes some healthy, viable
subcutaneous tissue. Another disadvantage is that the removal
of subcutaneous tissue may create an unaesthetic contour
deformity.
Tangential excision, as the name suggests, involves sequentially excising the layers of eschar in a tangential fashion until
a layer of viable bleeding tissue capable of supporting a skin
graft is encountered [see Figure 8].28,29 The goal is to remove
only the nonviable tissue, particularly in the case of deep
dermal wounds. Typically, tangential excision is performed
with a handheld knife (a Watson knife or a Weck/Goulian
blade). A back-and-forth carving motion is used, and very
little force is applied. The guard on the knife can be used

The best replacement for lost skin is clearly skin itself. The
first known report of skin grafting comes from the Sushruta
Samhita, an ancient Indian surgical treatise that may date
back as far as the seventh century bc. This text describes the
use of both skin flaps and grafts for the repair of mutilations
of the nose, the ears, and the lips. The Indian method of
grafting was first introduced to Western medicine by English
surgeons, who observed it during the late 18th century.34

Figure 8 Tangential excision of the burn wound is carried

out with a Watson knife (as shown here) or a Weck/Goulian
blade. Eschar is tangentially excised until healthy, bleeding
tissue that is suitable for skin grafting is reached.

Figure 9 Extremities can be suspended from operating room

ceiling hooks to facilitate exposure for burn excision and
grafting.

skin grafting

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7 TRAUMA AND THERMAL INJURY
It was not until 1804 that successful transplantation of
free skin grafts was reported by Baronio of Milan, who
successfully grafted large pieces of autogenous skin onto different sites on sheep.34 In 1869, Jacques Reverdin, in a report
to the Socit Imperiale de Chirurgie, described the use of
a small epidermal graft, which became known as the pinch
graft.35 This technique did not, however, gain wide recognition until 1870, when successful experiments in skin grafting
for the treatment of burn patients were performed by George
David Pollock.36 In 1872, Ollier described the use of both
full-thickness and split-thickness skin grafts and realized
the possibility of covering large areas with such grafts if a
satisfactory method of cutting them could be devised.34
Currently, a 95% success rate is the standard of care
for skin grafting. To achieve this level of success requires
adequate wound bed preparation (see above), careful selection of suitable donor sites, and appropriate postoperative
care.
Skin grafts are broadly classified as either full-thickness
or split-thickness grafts, depending on whether they contain
the full thickness of the dermis or a partial thickness. Splitthickness grafts are further categorized as thin, intermediate,
or thick, depending on the amount of dermis harvested with
the graft. The thinner the skin graft, the greater the degree of
contraction that occurs at the recipient site after engraftment.
Although thicker grafts have the advantage of contracting
less, they leave a greater dermal deficit at the donor site,
which can lengthen the time needed for healing and increase
the risk of hypertrophic scarring at that site.
Full-thickness skin grafts can be harvested either through
use of a dermatome or through direct excision of skin from
the flank, the groin crease, the hypothenar eminence, or
the forearm and can be used for coverage of small defects of
the hand or the face. Standard (intermediate) split-thickness
grafts are typically harvested at a thickness of 0.010 to
0.012 in. Thin (0.006 in.) split-thickness skin grafts are generally used in conjunction with skin substitutes, whereas thick
(0.018 to 0.025 in.) split-thickness grafts are typically used in
grafting of the hand and the face. The thickness of the graft
depends both on the dermatome setting and on the pressure
the harvester applies to the dermatome during harvesting.37
Donor-site selection for split-thickness skin grafts is based
on the distribution of the burn. The anterolateral thigh, when
available, is the donor site of choice for most adult patients:
it can be harvested in the supine position, it can easily be left
open to the air so the donor-site dressing can dry, and it can
be covered by shorts if desired. When larger grafts are needed
or the thighs are burned, the back, the buttocks, and the
abdomen can serve as donor sites. Subcutaneous infiltration
of a physiologic salt solution yields a smooth, firm surface
that facilitates the harvesting of these areas. If this is done,
the anesthesiologist should be informed that additional fluid
is being administered. In children, the buttocks and the scalp
are commonly employed as donor sites. Once healed, these
sites are usually inconspicuous: the buttock donor site can be
harvested in such a way that it can be covered by a bikini, and
the scalp donor site is typically covered by regrown hair. It is
important to reassure the patients parents that if the graft
is harvested appropriately, the donor site will not exhibit
alopecia and the recipient site will not grow hair. Generally,
however, these sites are sufficient only for the grafting of
small wounds.

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15 MANAGEMENT OF THE BURN WOUND 8
Skin grafts can be applied as sheet (or unmeshed) grafts,
or they can be meshed at ratios ranging from 1:1 to 4:1.
Meshing allows the egress of serum and blood from wounds,
thereby minimizing the risk that hematomas or seromas will
form that could compromise graft survival. In addition,
meshed grafts can be expanded or stretched to cover larger
surface areas. When grafts are meshed at ratios of 3:1 or
higher, allograft skin or another biologic dressing can be
applied over them to prevent the interstices from becoming
desiccated before they close.38 Because of the lack of dermis
in the interstices, widely expanded mesh always scars, takes a
long time to close, and results in permanent unattractive
mesh marks. In our center, widely spread mesh is never
used unless it is grafted onto a dermal template to minimize
scarring (see below).
Sheet grafts should be used on the face, the neck, the hands
[see Figure 10], and, whenever possible, the forearms and the
legs. In these exposed areas, the superior cosmetic and functional results obtainable with sheet grafts make such grafts
preferable. Because sheet grafts have no interstices, they must
be closely monitored and periodically rolled with a cottontipped applicator to drain any fluid collection. Any serous or
bloody blebs that form beneath the graft should be incised
with a No. 11 scalpel and drained expeditiously. A common
practice known as pie-crusting, which involves making incisions in a sheet graft at the time of surgery, actually does not
yield much improvement in graft survival, because blebs often
form in areas without incisions. Use of fibrin sealant at the
time of grafting may lower the incidence of blebs.39
graft and donor-site dressings
Once the graft is secured in place, a dressing may be applied
to protect it from shearing, as well as to accelerate closure of
meshed graft interstices. Numerous options for graft dressings exist, including wet dressings and greasy gauze. The use
of a nonadherent dressing such as Conformant 2 (Smith &
Nephew) along with an outer antimicrobial wet dressing
allows the overlying dressings to be periodically removed
without dislodging the graft from the wound bed. Bolsters
consisting of cotton and greasy gauze are employed to help
grafts conform to concave wound surfaces, and splinting of
extremities may be necessary for safe graft immobilization,
especially over joints. A vacuum-assisted closure system can

Figure 10 Sheet grafts are the gold standard for skin grafting
of the face, the neck, and, whenever possible, the forearms
and the legs. This 1-month follow-up demonstrates the
aesthetic superiority of sheet grafts.

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7 TRAUMA AND THERMAL INJURY
be used as another option for promoting graft healing. Alternatively, an Unna boot can be placed on both the upper
and the lower extremity to immobilize the graft and provide
vascular support, allowing mobilization of the extremity in
the immediate postoperative period.40
Sheet grafts can be either left open to the air to allow continuous monitoring or wrapped with dry dressings, which can
be removed if necessary to allow interval inspection and
deblebbing.
There are also various options for donor-site dressings.
The ideal donor-site dressing would not only minimize pain
and infection but also be cost-effective. Greasy gauze or a
nanocrystalline silverembedded material is often employed
for this purpose. Typically, these dressings are left in place
until the donor site epithelializes, at which time the dressing
is easily separated from the healed wound. Op-Site (Smith &
Nephew), a transparent polyvinyl adherent film, is also commonly used. With Op-Site, the underlying wound is easily
examined without removal of the dressing; however, intermittent drainage of the wound fluid that accumulates is necessary. Op-Site does not work well over joint surfaces and
concave or convex areas (e.g., the back). Silver sulfadiazine
in a diaper is an excellent covering for buttock donor sites in
children; dressing changes can be done with each diaper
change.
postoperative wound care
Even with complete graft take and timely donor-site epithelialization, several wound management issues may still arise
in the early postoperative period. Physical therapy must be
initiated in this period, and management of scarring must be
addressed. Blisters are common on newly healed donor sites
and ungrafted wounds. The new epithelial layer of these
wounds lacks the connections to the underlying wound bed
normally provided by the BMZ, which protect the epidermis
from shearing. During the months it takes for these structures
to reconstitute, their absence frequently leads to blistering.
These blisters are usually best managed by draining them
with a clean pin, reapplying the epithelial layer to the wound
surface, and covering the site with adhesive bandages. The
bandages can be soaked off in the shower to ensure that the
adhesive causes no additional injury.
Inclusion cysts may develop in healed grafts that were
placed over excised wound beds that still contained a thin
layer of dermis with adnexal structures. The secretions from
the adnexal structures collect beneath the skin graft to form
the cysts. Inclusion cysts are treated by unroofing the affected
area with a needle.
A condition known as sponge deformity (so called because
the skin looks like a bridge of coral sponge [see Figure 11])
may occur if a skin graft is placed over a wound that heals
underneath the graft in multiple small areas, with or without
sloughing of the overlying graft.41 Where the graft does not
slough, a bridge forms. This unsightly deformity can be
treated by incising the bridges over the healed tissue with
sharp scissors.
Healed donor sites, skin grafts, and ungrafted burns can
also break down as a result of infectiona process referred to
as melting. Such melting can occur quite rapidly: a graft or
healed wound that demonstrates complete take one day may
exhibit significant breakdown the next day. Wound cultures
should be obtained from these areas, and the open sites

ACS Surgery: Principles and Practice

15 MANAGEMENT OF THE BURN WOUND 9

Figure 11 Sponge deformity can occur if a skin graft is

placed over a wound that heals beneath without sloughing of
the overlying graft. Arrows depict the bridge of skin graft (a)
that forms over healed skin (b).

should be treated with topical antibiotic ointment and, if the

problem worsens, systemic antibiotics.41
Malignant degeneration can occur in healed burn wounds
decades after the initial injury. These tumorsknown as
Marjolin ulcersare usually squamous cell carcinomas and
are more aggressive than typical skin cancers. Marjolin ulcers
have a high metastatic potential and are associated with a
high mortality. New or chronic ulcers in burn wounds should
raise the suspicion of malignancy and be considered an
indication for biopsy.43
biologic dressings and skin substitutes
As noted [see Early Excision and Grafting, above], conventional burn wound management dictates early, aggressive
excision of burn wound eschar to minimize the chances of
sepsis or progression of burn wound depth.15,16,2124 In some
cases, the body surface area to be excised is larger than can
be covered by autografts from the available donor sites. The
solution is to strategically select areas for autograft coverage
and then temporarily cover the remaining open areas with
biologic dressings. Donor sites typically epithelialize within
about 2 weeks, after which time they can be reharvested,
allowing temporary dressings to be serially removed and
covered with new autograft.26,44
Biologic dressings perform several important functions. By
adhering to the wound bed, they provide a physical covering
that controls water vapor transmission, thus minimizing loss
of water, electrolytes, and proteins and preventing desiccation
and maceration of wounded tissue (which can lead to extension of the depth of injury). In addition, biologic dressings
help prevent microbial invasion from the environment.26,45,46
allograft and xenograft skin
Although the technique of skin grafting is thousands of
years old, skin grafting between individuals was not reported
until the late 19th century. In 1869, Reverdin published a
report on the transplantation of small epidermal grafts from
his own arm onto a patients burn wound.35 In 1881, Girdner
described transplantation of skin grafts from a cadaver to a

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7 TRAUMA AND THERMAL INJURY
burn patient and reported a 75% immediate take rate. It was
widely noted that these grafts initially performed well but
survived for only 6 to 8 weeks.34 The mechanisms underlying
the rejection of these grafts were eventually elucidated by the
efforts of Sir Peter Medawar, who received the Nobel Prize
in 1960 for his seminal work on defining the basis of allograft
rejection and tolerance induction.
The use of allograft was popularized by James Barrett
Brown in the 1940s and 1950s,47 and with the subsequent
development of skin banking, allograft became the standard
temporary graft for excised burn wounds when sufficient
autograft is unavailable or autografting is not indicated.26,27,46,48,49
Ultimately, allograft skin is always rejected unless the donor
and the recipient are immunologically identical. The rejection
process usually begins within 10 days in an immunologically
competent host, but allografts can be tolerated for up to 1
month in a host who is severely immunocompromised (e.g.,
as a result of extensive burn injury).26,49,50 The use of immunosuppressive agents such as cyclosporine has led to the
achievement of prolonged allograft tolerance,24,5053 but it also
exposes the burn patient to the risks inherent in prolonged
systemic immunosuppression.
In addition to providing temporary wound closure, allograft
has been used as an overlay for meshed autograft with the
aim of accelerating epithelialization of the interstices. Allograft
has also been used to cover donor sites after autograft
harvesting and to cover wounds after excision as a means of
assessing the suitability of a bed for autograft placement.21
Recognition of the weaker immunogenicity of the dermal
layer of cadaver allograft stimulated various attempts to
employ allograft for permanent dermal replacement. Jackson
and colleagues were the first to report the use of alternating
strips of autograft and allograft for definitive closure of large
burn wounds.19 In 1985, Heck and colleagues constructed
the first deliberate combination of allogeneic dermis with
autologous epidermis.54 This basic idea was subsequently
expanded on by Cuono and colleagues, who used cryopreserved allogeneic dermis as a bed for autologous keratinocyte
cultures.3,55 These investigators demonstrated long-term
survival and documented the reconstitution of a normalappearing BMZ with anchoring fibrils.
Use of allograft skin as a temporary cover or as the permanent dermal replacement in the composite technique does
have several drawbacks, including the limited availability of
suitable skin, the variable quality of the skin obtained, the
substantial cost of allograft procurement and preservation,
and the significant potential for disease transmission.56,57
In addition, the cryopreservation process significantly compromises the viability, and therefore the efficacy, of the
allograft.58,59
Xenografts from a number of species have also been used
as biologic dressings. Porcine xenograft has been used in the
management of exfoliative skin disorders (e.g., toxic epidermal necrolysis) as well as for temporary wound coverage after
excision and before definitive autografting.26,6062
Since the 1980s, research efforts have focused on the development of skin replacements that could serve as either a
temporary or a permanent substitute for human skin. Conceptually, any skin replacement must recapitulate the native
skin biologythat is, it must include an epidermal component, a dermal component, and a BMZ equivalent linking the
two.

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15 MANAGEMENT OF THE BURN WOUND 10
cultured epidermal autografts
Replacement of the epidermis alone was successfully
accomplished in the 1970s with the development of cultured
epidermal autografts (CEAs). In 1975, Rheinwald and Green
reported the successful isolation and culture of epidermal
keratinocytes,63 and several years later, OConnor and colleagues reported the first clinical use of CEAs to cover burn
wounds.64 In 1984, Gallico and colleagues described the use
of CEAs to resurface the burn wounds of two children who
had sustained injuries over 95% of their TBSA.65 CEAs are
grown in the laboratory from a biopsy of the patients own
skin. A current example is Epicel (Genzyme Biosurgery,
Cambridge, Massachusetts), which has been approved by the
Food and Drug Administration (FDA) for use in the United
States but requires Institutional Review Board approval and
separate informed consent because of concern that the feeder
layer for the keratinocytes is of murine origin.
CEAs are most commonly applied to the granulation tissue
of chronic wound beds. As more clinical experience with
CEAs was amassed, the drawbacks of using epidermal components alone to replace full-thickness skin loss became
evident.27,6668 The lack of a dermal component made the
CEAs extremely fragile and led to high rates of sloughing and
infection.27,69,70 Even when CEA engraftment occurred, the
BMZ structures critical to graft durability were poorly reconstructed.6971 Compton and colleagus compared the outcome
of wounds covered with CEAs alone with the outcome of
wounds covered first with allograft dermis and then with
CEAs. They found that in wounds containing the allograft
dermal component, there was greater initial take, better longterm durability, and accelerated formation of important BMZ
structures.72 It is now well recognized that CEAs are capable
of replacing the epidermis but are not effective when used
alone to resurface deep partial-thickness and full-thickness
wounds. Bilayer skin substitutes consisting of both dermal
and autologous epidermal cultured cells are being developed
to reduce the time for maturation on the patient.27 Although
the theoretical applications are vast, the successes of these
products have never been demonstrated in prospective randomized trials. Another potentially promising concept is use
of dispersed cells in conjunction with widely meshed grafts to
decrease time to closure and decrease scarring.73
In vitro development of an epidermal replacement was
made possible by the simpler biology of the epidermis. Development of a dermal replacement has proved a more formidable challenge. Dermis consists mainly of extracellular
matrix, and its complex structure is not amenable to growth
in culture.
skin substitutes
The drawbacks of allograft and xenograft skin have further
underscored the need for an off-the-shelf dermal replacement. Yannis, Burke and colleagues described a pioneering
approach to the development of a skin replacement containing both an epidermal and a dermal component in the
early 1980s.7477 Recognizing the importance of the dermis in
skin replacement, they developed a bilayer construct that is
now commercially available under the name Integra (Integra
LifeSciences Corporation, Plainsboro, New Jersey). The epidermal component of this construct consists of a layer of
Silastic film, which acts as a protective barrier against infection and evaporation from the wound bed; the dermal layer

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7 TRAUMA AND THERMAL INJURY

ACS Surgery: Principles and Practice

15 MANAGEMENT OF THE BURN WOUND 11

Figure 12 A bilaminar skin substitute is placed on the excised burn wound (a) and secured with staples. The skin substitute
typically vascularizes in 2 weeks, at which point the Silastic outer layer is removed (b) and the neodermis can be autografted.

consists of a porous matrix of fibers composed of cross-linked

bovine collagen and a single type of GAG (chondroitin6-sulfate). Integra can be placed on a completely excised,
noninfected wound bed. Initial studies indicated that a neodermis forms, created by the ingrowth of fibroblasts and
endothelial cells into the dermal matrix template provided
by the Integra. Once this neodermis forms and the dermal
scaffold is well incorporated into the wound (typically,
after 14 days), the Silastic component is removed. A thin
(0.006 in.) split-thickness autograft is then placed on the neodermis [see Figure 12].27,78,79 Integra not only is a useful adjunct
in the management of large burn wounds but also can play
an important role in the management of hand and facial
burns requiring excision and grafting.8082 It must be emphasized, however, that for Integra to vascularize completely,
it must be applied to a viable, noninfected wound bed.
In addition, meticulous surgical technique and appropriate
postoperative care are critical for a successful outcome.
Another product marketed for dermal replacement is
Alloderm (LifeCell, Branchburg, New Jersey), which is an
acellular dermal matrix produced from human cadaveric skin.
The cadaveric skin is first stored in normal saline for 15 hours
to remove the epidermal component. The cadaveric dermis is
then incubated in sodium dodecyl sulfate to extract any
remaining cellular components. The decellularized substrate
is freeze-dried and reconstituted by soaking it in crystalloid
solution before use.26 Alloderm can be used for immediate
wound coverage in combination with a thin split-thickness
autograft. Data from multicenter trials indicate that Alloderm
works best with thin (0.006 to 0.008 in.) autografts: the

thicker the autograft, the lower the take rates.26,27,83 Alloderm

has also been used for abdominal wall reconstruction and for
soft tissue augmentation in the face.
A product known as TransCyte (Smith & Nephew)
formerly Dermagraft-TCis approved by the FDA as a
temporary (as opposed to permanent) cover for full-thickness
wounds after excision. TransCyte is produced by seeding
neonatal fibroblasts isolated from foreskin onto Biobrane, a
synthetic dressing consisting of Silastic attached to a nylon
mesh, which is coated with porcine peptides prepared from
type I collagen. The Silastic layer of Biobrane serves as a
temporary impermeable barrier, whereas the fibroblastimpregnated nylon mesh serves as a dermal component.26,27
Dermagraft (Smith & Nephew), in contrast, is employed
as a permanent dermal replacement. Dermagraft consists
of human neonatal fibroblasts seeded onto an absorbable
polyglactin mesh scaffold, which is intended to mimic the
native dermal architecture.26,27 It is approved by the FDA
for treatment of venous stasis ulcers, but it was developed
for coverage of excised burn wounds in conjunction with a
split-thickness autograft.
Although a permanent off-the-shelf skin replacement
has yet to be developed, the available products have already
significantly influenced the management of burn wounds. In
addition, the shortcomings of each product and strategy have
improved our understanding of skin biology and physiology
and confirmed the importance of both the epidermis and the
dermis in the structure and function of skin.
Financial Disclosures: None Reported

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Acknowledgments
Figure 1 Tom Moore
Figure 2 Seward Hung

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