Early excision and skin grafting in burns by Dr. Sunil Keswani, National Burns Centre, Airoli
1. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com, nbcairoli@gmail.com
DR SUNIL KESWANI
Plastic Surgeon
NATIONAL BURNS CENTRE,Mumbai
2. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Always early excision if patient comes early
enough and facilities exist
Early enough is upto 72 hrs postburn
Early excision decreases the chances of Sepsis
and facilitates early moblisation and better and
more predictable functional recovery.
Delayed excision is generally at 3 weeks or later
3. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Within the first 3-5days
After 5 days chances of Sepsis higher and
bleeding more
15% of BSA is excised at a time
Coverage of excised area by Meshed
Homograft is mandatory
4. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Areas easy and quick to excise: trunk
and legs
Joints and throats
Hands and face
5. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Blood Loss
Clear pre-operative plan
Excision prior to wound hyperemia
Elevation of extremities
Tourniquet control
Dilute Epinephrine tumescent fluid
Epinephrine soaked sponges
6. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Procedure (En Bloc)
For deeper burns
Skin and fat excised in one session
Less time consuming
Excision down to the natural cleavage plane
Down to fat or Fascia
7. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Classic benefits of allograft as a physiologic and
mechanical barrier:
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Reduction in water, electrolyte and protein
loss
Reduction in energy requirements
secondary to the attainment of a closed
wound
Reduction in wound infection rates
Reduction in pain
Conservation of autografts
Improved general welfare and
psychological outlook of the patient
8. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Reduction in the number of bacteria under a
biological dressing
Phagocytes within a wound use the fibrin
network established between the allograft and
the wound to trap and phagocytose bacteria
without the production of opsonins or
antibody
The effects of allografts in reducing bacteria
and promoting healing have proven beneficial
9. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
10. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
11. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Materials that are applied for short periods
then removed, to stimulate autologous healing
Cell free material that encourage colonization
by autologous cells, to stimulate new skin
formation
Cell containing skin substitutes: to provide
immediate functional replacement
12. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
13. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Most widely accepted synthetic skin substitute
Bilaminar structure
The median ‘take’ is 85%
Two-stage procedure, with a minimum interval
of 3 weeks between the application of the
Integra and the split-skin grafting
Relatively expensive
14. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
15. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
16. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
17. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
18. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
19. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Grown in vitro and then applied to wounds
Take of cultured epithelial autografts depends
on the wound bed
Expensive
Skilled labour and quality control,
3–5 weeks to produce 1.8m2 confluent
sheets of cells from a 2 cm2 biopsy
Fragile sheets
Blistering, infection, and contractures.
20. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Suggested Clinical Indications for CAE
burn injuries >90% broad
70-90% more limited
<70% no clear indication
21. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com, nbcairoli@gmail.com
22. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Acute burns always meshed or meek
micrografting for better takes
Reconstructive procedures like overgrafting
and release of contractures always sheet
grafting for better cosmesis
Meek micrografting gives wider coverage and
more predictable takes than mesh grafting but
more expensive
23. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
24. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
25. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
26. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
27. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
28. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
29. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
30. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
31. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
32. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
33. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
34. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
POST-PHYSICAL REHABILITATION OUTCOME
35. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
36. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
37. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
38. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
39. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
40. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
41. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
42. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
43. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
44. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
45. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
46. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
47. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
48. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Pre-Op wound
Application of Homograft
Day 3
Complete healing
Day 21
49. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
50. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
51. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
52. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
53. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com, nbcairoli@gmail.com
54. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
55. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
56. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
57. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
58. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
59. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
60. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
61. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
62. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
63. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
64. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
65. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com, nbcairoli@gmail.com
THANK YOU
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Notas do Editor
{"5":"Blood loss\naverages 134ml/% excised (1st day 100mL/%, 4th day 200mL/%\nAlternatively 8.8% of circulating blood volume is lost for each 1% excised.\nTourniquet\nEsmarch bandage followed by pneumatic tourniquet 100mmHG above SBP\nExcise through grey/brown tissue to white glistening dermis or bright yellow fat.\nApply grafts prior to letting down the tourniquet.\nApply a pressure bandage\nReports decreasing blood loss to 29mL/% excised BSA.\n","6":"Fat or Fascia\nNo difference in graft take if fat is viable. Better contouring if fat is preserved.\n","13":"Inner layer is 2mm thick and is a combination of GAG and collagen fibers from bovine tissue\nInner layer has 70-200 nm pore size that allows fibrovascular ingrowth, after which it is designed to slowly biodegrade\nOuter layer is 0.009 inches thick polysiloxane polymer with vapor transmission characteristics similar to normal epithelium\n","19":"such asburns, chronic leg ulcers, giant pigmented naevi,epidermolysis bullosa and neonatal scalp necrosis\nseparation from the tissue culture substrate using a proteolytic enzyme\nspontaneous blistering many months after grafting, increased susceptibility to infection, and contractures\nBovine serum proteins\nact as growth promoters\nDelayed loss of graft\ninitial take 64% declined to 47% at discharge for one study of 16 patients\nCost $2000-34 000 pr percent of definitive wound closure at discharge.\nBlistering\nassociated with high PGE2 and thromboxane levels suggesting an ongoing inflammatory response\nEffects of fibrin glues being evaluated with limited success\nFibrin-glue suspensionSome success has been achieved by applying cells together with fibrin glue, in a suspensionof growth medium or using a membrane for delivery.\nFibrin-glue sheets. Subconfluent cultured keratinocyteshave been grown on fibrin glue, and then transferred as asheet onto the wounds in three patients with excised fullthicknessburns. The fibrin was found to provide a satisfactorybarrier for 10 days, \n","20":">90% burns\nlimited donor sites\ncan contribute to limited wound closure in a potentially y important manner\n70-90-%\nclinical judgement depending on the donor sites\ne.g. face feet hands and genitalia are difficult to harvest \n<70% TBSA\n not usually necessary\n"}