APPENDIX F: BURN EXCISION AND GRAFTING

Burned patients should undergo evacuation to a role of care capable of prolonged burn care, however, if evacuation is not possible, a surgical team may need to perform definitive burn care (excision and grafting). If members of the surgical team have not had recent experience with burn care, contact the USAISR Burn Center or Advisor Line for assistance.

EXCISION OF THE BURN WOUND INDICATIONS:

- Large (>2%) deep burns to critical areas (hands, feet, face, joints)
- Deep partial-thickness burns not demonstrating wound healing by day 7
- Burn infection (stopped healing or have signs of erythema)

EQUIPMENT:

1. Prep
2. Sterile drapes
3. Weck, Goulian, dermatome, or amalgatome
4. Electrocautery device
5. Epinephrine-soaked gauze
6. Post-op dressings

PROCEDURE:

1. Use a guard with a depth of 0.008-0.012 inches for excision; deeper burns will need the larger guard.
2. Optional: place an orthopedic tourniquet for large burns to minimize blood loss. Keep tourniquet time <1hr.
3. Place the blade and guard on the burned skin firmly at a 30–45° angle. Press downward on the burn and move the knife in a slicing motion.
4. Excise down to healthy bleeding tissue (if using a tourniquet, look for healthy tissue).
5. Place epinephrine-soaked gauze over excision and obtain hemostasis with cautery.
6. Autograft (See grafting below) or place dressings.
7. Place topical antibiotic ointment + xeroform gauze for deep partial thickness or a wound vac/wet to dry for full thickness injury.
8. Re-examine in 48-72 hours (sooner if showing systemic/local signs of infection) to ensure no further excision is needed or the wound bed is ready for grafting.

SKIN GRAFT HARVEST AND GRAFTING

Autologous autografting involves taking a segment of skin (epidermis and a portion of the dermis) and placing it on a viable wound bed. A dermatome (or amalgatome) will be needed for grafting. If a large areas are needed to be grafted, a mesher is ideally used to increase the graft coverage. If available, the anterior and lateral thigh is the best option for donor skin.

PROCEDURE:

1. Prep skin (donor site and wound bed ready for grafting ) and drape.
2. Choose width of Dermatome guard (usually 3-4 inches) and set to a depth of 0.010-0.015 in.
3. The skin being harvested must be kept taught to avoid skipping of the Dermatome. This can be done by using a tumescent solution (500mg lidocaine, 0.5mg of epinephrine and 10 mEq of sodium bicarbonate in 1 L of Normal Saline) injected subdermal to raise and tighten the epidermis evenly to allow the Dermatome to pass evenly over the donor site. The skin can also be kept taught be keeping it under tension with manual pressure or using two penetrating towel clips and pulling on the skin to keep it taught.
4. Place sterile oil (mineral oil) or dilute surgical soap on the site to reduce friction while harvesting.
5. Turn the dermatome on and place it firmly at a 30-degree angle and advance slowly – maintain steady pressure the entire time (pushing hard will not increase the depth of the graft, but pushing too little will result in a thin graft).
6. Watch the donor skin to ensure depth is appropriate (thin portion of white dermis). If this is not seen, increase depth by another 0.002 inches.
7. Near the completion of the graft, flatten the angle and lift away from the skin. If this does not detach the graft from the donor bed, a scalpel or Metzenbaum scissors can be used to transect the graft.
8. Place episoaked gauze on the donor site.
9. Prepare skin graft – pie crust or mesh (1:1.5 or 1:2 is most commonly used).
10. Ensure hemostasis of the donor site and wound bed.
11. Place graft in the wound bed and secure to the wound edges using staples or 4-0 chromic/nylon. Fibrin glues may be used in the wound bed to assist with adherence (if desired/available).
12. Autograft dressing options:
    - Xeroform© (or Adaptec© or Telfa©), over the autograft. Topical antibiotic on top of the Xeroform. Then kerlix to secure. OR
    - Nonstick dressings over the autograft (above) and then wound vac sponge (black) and then secure the vac sponge with the accompanying supplies. Place suction to 100-125mmHg. OR
    - Moisten silver-impregnated bandage and cover the graft. Then place ABD pads and wrap with kerlix.
13. Donor site dressing options:
    - After hemostasis, place xeroform directly on the donor site. Cover with ABD pads and kerlix to secure. OR
    - Moisten silver impregnated dressing and place directly on the wound. Then wrap with Kerlix. OR
    - Tegaderm directly onto the donor site, and secure with an ace bandage.