Primary excision and immediate wound closure

Surgical principles of early excision of devitalized tissue and prompt wound closure which govern the management of all traumatic injuries have been developed in the primary treatment of burns. Topical and systemic antibodies which delay wound infection and control invasive sepsis provide an initial period of two to three weeks in which wound excision and closure is safe and effective. Full support of the central and peripheral circulation, respiratory function, nutrition, and musculoskeletal function are essential features of care until the burn wound is eliminated and closed. Following initial evaluation, wound excision is carried beyond the deepest level of injured tissue. Excision to the level of muscle fascia is used for full-thickness injury and sequential excision in or below the dermis for deep dermal injury. Techniques of skin grafting and subsequent care of the graft are described, including the use of human allografts. Primary excision has reduced mortality, morbidity and later reconstructive measures by a factor of 50% when compared to results obtained by awaiting spontaneous separation of eschar with later grafting. With massive burns the use of allografts from familial donors of close immunologic type and immunosuppression of the patient prolong the period before allograft rejection and permit repeated harvest of the patient's donor sites for permanent wound closure. Over 60% of young burn victims with greater than 70% full-thickness burn injury have survived with this method of treatment.