Wounds are typically debrided in one of two ways depending on the amount of tissue that needs to be removed.
In non-excisional debridement, the wound is vigorously washed or scrubbed without using a knife or scissors. Non-excisional debridement is performed by the nurse and then by the patient or family after discharge. Pain medicines are given by mouth one hour prior to the procedure, and often additional pain medicines are given by IV during the procedure. The ability to tolerate non-excisional debridement without intravenous pain medications is one of the criteria for discharge from the hospital.
Excisional or sharp debridement is done with a knife or scissors in the operating room under anesthesia. The goal is to remove all the tissue that is not healthy, i.e., any tissue that is dead or severely infected. Oftentimes this type of debridement will require reconstruction with skin grafts or flaps.
Often with burns or other complicated skin diseases, scar formation occurs. The scar may create cosmetic concerns that lead the patient to ask for revision, or functional concerns that limit the ability of a joint to move. Functional concerns typically will require surgical scar revision. The burn team is skilled and experienced at scar revision and can employ a variety of techniques such as skin grafts, rotation flaps, or local flaps to improve the appearance of the scarred tissue as well as mobility. The goal is to maximize cosmesis (appearance) and function.
Amputations are an extension of sharp debridement (see Wound Debridement, above) in situations in which the tissue is dead or too infected to save. Often the dead or infected
tissue includes the bone, so the body part has to be removed to allow for the patient to survive and to begin the reconstruction process.
The most common amputation in burns is finger amputation. All efforts are made to avoid amputation, but when it is required, we remove as little of the affected finger(s) possible.
Another amputation that unfortunately happens with some frequency is amputation of the foot in patients with diabetes and burn to the foot. Diabetics often have loss of sensation and are unable to tell how hot water is by testing the temperature with
a foot. Diabetic patients should examine their feet daily and avoid hot and cold environments to avoid burn injury or frostbite injury.
Skin grafting is harvesting donor skin from one part of the body and transplanting to another part of the body.
If the skin comes from your own body, it is called an autograft, and autografting is the final step for wound closure.
If the skin comes from the skin bank, it is called an allograft because it comes from another person. When people donate their organs, they also donate their skin. Allograft is used for temporary closure, but it will always
be rejected and ultimately need to be replaced with autograft.
Sometimes, we use pig skin as a temporary bandage over burns, and this is called xenograft.
Autografts: Sheet vs. mesh
An autograft can be meshed or placed as a sheet graft.
Sheet grafts are less scarring; however, they require more donor skin to cover a burned area.
Meshed grafts are used when a large burn needs to be covered and there is not much donor skin available. Meshed grafts heal with a fishnet-like appearance that fades over time but never smooths out completely.
Full-thickness circumferential burns can impede blood flow to hands and feet and can compromise breathing if the entire chest is burned. In an escharatomy, incisions are made, just through the burn, to allow tissue expansion and improve circulation or breathing.