Maximizing Micrograft Take in Extensive Back Burns

Extensive burns involving the back pose unique challenges. Offloading in the prone position is not possible with concomitant deep facial and neck burns. We describe our experience in maximizing graft take in a patient who had extensive back burns with concomitant anterior body burns. The two main goals in graft fixation for extensive back wounds are mechanical stabilization of micrografts to reduce shearing and prevention of water logging from exudates or bleeding to optimize contact with wound bed. Guided by the stages of wound healing, graft take, and burn care, we describe three stages of postoperative negative pressure wound therapy (NPWT) in a patient with 54% TBSA burns treated with micrografting. After complete excision of the deep dermal burns of the entire back, the wounds were covered with micrograft-allograft composites. In phase I, days 1 to 3, conventional topical negative pressure dressing with a thin sponge was applied and a leak-proof seal was achieved with gel sealant and high tack adhesive drapes. In phase II, days 4 to 5, foam dressings with topical negative pressure were applied, but with a less stringent seal, supported by wall suction. In phase III, the selective removal of allografts was initiated to facilitate expansion of micrografts. Negative pressure was continued for another 2 weeks at the most dependent site to prevent wound maceration from exudates. Micrograft take was optimized with the patient in the supine/semirecumbent position. The back wounds healed completely between 60 and 70 days without repeat micrografting. Since prone positioning was not possible in this patient, clearance of exudates and maintenance of micrograft contact with the wound bed using this technique proved successful.