Sulaimanya Burn Centre

Prepaired by: Dr.QutaibaAbdullahYassin

Introduction
Several
historical
figures
also
favored
excision
of facial
burns
Introduction
EXCISION AND GRAFTING OF ACUTE FACE AND NECK
BURNS
Evaluations/4
The technique for the excision and
grafting is described later and has
not changed since
the 1986 publication except for one
thing-the delay
between allograftingand
autograftingis 1week instead
.of 2 days
The operation

Those aesthetic units

judged
to be incapable of healing
within 3 weeks of the injury
.are outlined with markers
Special OT Notes
Small unburned or healed
areas must frequently be included in the excision to
.preserve the aesthetic unit

In some circumstances, a
portion of an aesthetic unit will clearly not heal in 3
weeks, but the area is small enough to be reconstructed
.later by excision and closure or with tissue expanders
In this situation, excision and grafting either are not
performed or are done with routine grafts

One must excise deeply enough to

prevent the bed from healing underneath the graft with
resultant graft loss This is accomplished by excising
deeply enough to remove the hair follicles
 The T-shaped central area of the face

The eyelids are usually excised/1

first The
hemostasis is achieved with bipolar cautery Goulian
and epinephrine (I : 10,000)-soaked
dermatome
.Telfa pads
with the
The medial canthal regions are done next./2 O.OO8-
The excision is usually done inch
.with curved iris scissors or a No. 15 blade
guard
,The next area to be excised is the nose/3 is used
for
The upper lip is then excised/4

lower lip and chin /5,6

:leaving the four large flat areas
the2-cheeks,the forehead, and the neck

The Goulian dermatome is again used

but with the O.OIO-inch or 0.012-inch guard

Typically, it is not wise to excise

all four areas at the same time because the blood loss
can be substantial, requiring rapid transfusions to
.maintain blood volume
These areas are usually
.done serially
and the
excision continues to normal bleeding tissue with no
.remaining hair follicles
 Ear burns are not excised
because there is no
instrument
adequate to excise the three-
dimensional structure
.of the ear
After excision is complete,
each area is covered with
.allograft

The allograft is placed with all of

the attention to detail that is used for
autograft, that
is, it must be well secured with
,staples, sutures
Approximately I week postoperatively, the patient
.is returned to the operating room for autografting

The
allograft is carefully inspected to determine
whether it is adherent to the bed underneath. If
the allograft is loose, it may mean that the excision was
not deep enough, in which case the excision and allografting
.must be repeated
It is usually O.OI8 to 0.021 inch in thickness in adults and
0.008 to 0.0 12 inch in children and obtained from
the scalp if graft color must be matched with the color
of healed or unburned areas. If the entire face is to be
grafted, the scalp is insufficient,and the harvesting must
.be done elsewhere
 It is
important that the donor site
be planned shortly after
admission, before all donor
sites have been used to
.resurface other body parts
Each area of scalp is then infiltrated with large
volumes of saline
containing I : 500,000 epinephrine to make it flat or
nearly so. To achieve this, more solution is injected
around the perimeter of the site to be harvested than
in the center. This is done just before harvesting
because the fluid leaves the scalp rapidly

,from ear to ear over the top of the skull@

one from top of skull to nape of neck over the occipital@
,region
and two smaller residual pieces from each@
,posterolateral area
.Resulting in four pieces of autograft
"dressing
"dressing
,is then applied that consists of fine mesh gauze
the elastomer mold (or foam if sufficient), and a pressure
garment bubble (Bioclusive
is applied to the scalp, if it was )Johnson & Johnson(
harvested, and is held in place by the pressure garment
.bubble

.Duplicast mold
Bubble and elastome

.Plaster reinforcement

Bubble and elastomer

 Foll0w up

After circumoral grafting, splinting and exercises

.to minimize microstomia are necessary

Postoperatively, these devices are removed twice

daily. The grafts are inspected and any hematomas
removed, through I-cm incisions placed in the relaxed
skin tension lines. If hematomas are large, we do not
hesitate to return to the operating room and remove
the hematoma with general anesthesia. Patients are
given nothing by mouth for 3 days
Silicone sheeting is also
sometimes placed under the garments or masks in an effort to reduce
hypertrophic scarring

Until the grafts are mature, usually for several

.months, the patient wears pressure garments
.Steroid injections are used only rarely

are indicated (e.g., small hypertrophic

scars). The usual dose is 40 mglmL
,triamcinolone
.to 80 mg monthly for 6 to 9 months 40
thanks