Utility of Excision and Direct Closure in Burns: A Case Report and Review of the Literature

In the past years, the mainstay of burn treatment has been early tangential excision and skin grafting. Excision with direct closure is another reconstructive approach that has not been extensively explored. This study aims to review the existing literature on the utility of excision and direct closure, including prospective series, case series, correspondence, and randomized controlled trials. We also present our case report of a 12-year-old patient who sustained self-inflicted burns totaling 35% total body surface area (TBSA) and underwent bilateral mammaplasty, consistent with the excision and direct closure technique. The study finds that direct closure of burn wounds requires sufficient tissue laxity to allow tension-free closure. This technique has multiple advantages, including reduced burn surface area, decreased rates of hypermetabolism and infections, quicker healing time, shorter hospital stays, lower healthcare costs, and better esthetic outcomes. In our patient's case, her bilateral breast burns were initially treated with tangential excision and allograft, which were complicated by poor graft adhesion and pseudomonal colonization. Subsequently, the plastic surgery team excised burned breast tissues using the principles of reduction mammaplasty with superomedial-central pedicle to mobilize the remaining healthy breast parenchyma and skin to create an esthetic breast mound. No additional breast surgery was needed during the patient's remaining hospital stay. In summary, while having similar rates of postoperative complications to traditional burn treatment, excision and direct closure offer several advantages. However, primary closure may not be suitable for patients with an extensive burn surface area without an adequate tissue reservoir. Therefore, this technique should be further investigated as the treatment option for a selective burn population.