518 Changing Practice in the Surgical Management of Major Burns - Delayed Definitive Closure

Abstract Introduction Early (or immediate) eschar removal in major deep burns is proven to enhance survival. In all deep burns, the more rapidly the resulting wounds can be definitively closed, the better the outcome. However, in major burn injury, this is often protracted by the early physiological state of the patient and the paucity of donor site, mandating serial grafting. Dermal substitutes were developed to allow temporisation of such wounds and improve the functional and cosmetic outcome of graft-sparing techniques (widely meshed, thinner grafts). In developing such a matrix (BTM), we discovered that grafting immediately over fat yielded a poorer result than grafting over an integrated dermal matrix several (5) weeks later. Methods Subsequent to this finding, the next two significant burn injuries (70% and 75% TBSA, both with significant smoke inhalation) underwent immediate burn excision (within hours of the injury). Following two or three days on ICU, they returned to theatre for re-assessment, refreshing and the application of BTM to nearly all debrided wounds (face and neck burns, palm and sole burns were not treated with matrix). No early grafting was performed in the first patient. The anterior neck burns were excised and definitively grafted in the second on Day 26 to enable subsequent tracheostomy. Whilst BTM integration occurred, both patients physiologically improved. The first of four grafting procedures with 1:3 meshed autograft over the integrated matrix occurred at Day 43 in the first patient (then Days 50 & 65, completed on Day 72). The first of 3 began on Day 52 in the second (then Day 75, completed on Day 115). Results The early management course was markedly easier and more comfortable for both patients since painful and extensive donor sites were not created until they were physiologically better prepared to cope with them, many weeks post-injury. Graft loss over the integrated BTM was exceedingly uncommon. Reconstructive surgery for both patients has been subsequently required ONLY in areas that did not receive BTM (the first patient’s neck and palms to date). Conclusions Delayed grafting over a BTM yields a superior functional and cosmetic result than early grafting over fat. Early grafting creates early physiological insult when the patient can least afford it, whereas delaying allows greater physiological resilience (and psychological preparation). Applicability of Research to Practice These findings have completely changed ma