A two-stage technique for excision and grafting of burn wounds

While the technique of early excision and grafting has many advantages in the treatment of thermal injuries, it is not without significant complications. Hemorrhage accompanying burn wound excision can be deceptively great, as can the metabolic stress of large surgical procedures performed in the postburn period. In an effort to minimize these complications, we have developed a two-stage technique for excision and grafting of burn wounds. This technique employs layered excision of eschar, followed by an overnight stabilization period for restoration of normal body temperature and blood volume. Continuous soaking of excised areas promotes hemostasis, and insures a viable base for autografting performed on the following day. During 1978-1979, 117 burn patients underwent 137 two-stage excision and grafting procedures. Mean graft size was 1,988 cm2. Eighty-two per cent of the patients had all necessary grafting performed in a single two-stage operation, including grafts as large as 5,700 cm2. No graft loss occurred as a result of graft hematoma formation. Mean blood loss calculated for each two-stage operation was 2,627 cc, one third of which resulted from the harvesting of autografts. Temperature decrease during surgery was also great, with significant hypothermia occurring in 51% of procedures exceeding 2 hours in length. We conclude that performing excision and grafting in two stages limits hemorrhage and heat loss from each individual surgery, thereby permitting the performance of larger procedures. Nonetheless, continued awareness of the magnitude of these complications remains an essential of successful excisional therapy.