Early Tangential Excision and Immediate Mesh Autografting

of Deep Dermal Hand Burns

JOHN L. HUNT, M.D., RONALD SATO, M.D., CHARLES R. BAXTER, M.D.

Thermal injuries to the hand constitute not only one of the most From the Department of Surgery, University of Texas
common burns, but one of the most difficult for the burn Health Science Center, Dallas, Texas
surgeon to treat. Early wound closure is mandatory if maxi-
mum functional return is to be attained and scarring mini-
mized. Over the last three and one-half years, 60 patients with
deep dermal dorsal hand and finger burns were treated by
tangential excision and immediate mesh autografting. All pa- Materials and Methods
tients were admitted to the hospital within 24 hours of injury
and excision was performed between the third to the tenth post Over the last three and one-half years, 60 patients
burn day. Operative technique consisted of sequential eschar
excision using the Humby knife or Goulian-Weck dermatome with deep dermal dorsal hand and finger burns were ad-
until viable dermis was visible. Mesh autograft, ratio 1 to 11/2 mitted to Parkland Memorial Hospital Burn Unit.
without expansion, was applied. There was 100% graft take in There were 50 males and ten females. The average
all but four hands. Hand function with full range of motion re- age was 36 years with a range of 1-83 years. The
turned by the tenth postoperative day. Complications were average total body surface burn was 35% with a range of
minor. Patient follow-up ranged from six months to three and
one-half years. No patient has required subsequent surgery for 1.5-68%. All patients were admitted within 24 hours
scar revision or contracture release. Range of motion in all of injury and each received their initial resuscitation ac-
patients has been excellent and all patients have continued to cording to the Parkland Formula-4 cc of Ringer's
maintain normal hand function. The cosmetic appearance has lactate per kilogram per per cent burn in the first 24
been good except for the early "mesh" appearance of the graft hours. The burn wounds were initially cleaned with a
which has become less apparent with time. In summary,
early tangential excision and immediate mesh autografting of mild detergent soap and debrided. Silver sulfadiazine
deep dermal dorsal hand burns has fulfilled the following burn was applied and all hands were elevated. Blood flow in
principles -preservation of tissue, prevention of wound in- all extremities was assessed either by serial arterial pal-
fection, maintenance of function and early wound closure. pation or with the Doppler ultrasound meter. Escha-
rotomies were not indicated in any burned extremity.
HERMAL INJURIES TO THE HAND constitute not Burn wound excision was performed by the seventh
only one of the most common burns, but one of the postburn day in 49 patients and by the tenth postburn
most difficult for the burn surgeon to treat. Although day in 11 patients.
the dorsal surface of both hands and fingers constitute Based on previous clinical experience in instances
no more than 5% of the total body surface area, the where clinical differentiation between superficial and
short and long-term morbidity is incalculable in terms deep second degree burn is difficult, porcine hetero-
of pain, functional impairment, cosmetic appearance graft is applied to the wound 24 hours after the injury.
and financial loss. Although there is universal agree- If the heterograft is adherent to the wound 24 hours
ment that early burn wound closure is mandatory if after it application, the burn is treated conservatively.
maximum functional return is to be obtained and scar- It has been our experience that in such instances these
ring minimized, universal application of these prin- burns will heal in seven to ten days. Nonadherence of
ciples to the treatment of hand burns has not been the heterograft indicates a deeper second degree burn
adopted.5 injury, and a topical antimicrobial agent is reapplied
and excision performed at a later date.
Presented at the Tenth Annual Meeting of the American Burn
Association, March 30-31, April 1, 1978, Birmingham, Alabama.
Reprint requests: John L. Hunt, M.D., Dept. Surgery, Univ. Technique of Burn Excision
Texas Southwestern Medical School. 5323 Harry Hines Blvd.,
Dallas, Texas 75235. Eight hours prior to surgery, Povidone-lodine oint-
Submitted for publication: June 20, 1978. ment is applied to the burn surface. The application of
0003-4932/79/0200/0147 $00.75 C J. B. Lippincott Company
147
 HUNT, SATO AND BAXTER Ann. Surg. * February 1979
148
pads, a compression dressing and elevation of the ex-
tremity. The wound is left wrapped for approximately
ten minutes and if bleeding persists, the preceding steps
are repeated. The use of electrocautery for control
of bleeding is not recommended. It seems contra-
productive to create another burn on a freshly excised
viable wound bed. After hemostasis is obtained, auto-
graft at a thickness of .010-.012 inches and meshed at
1½2: 1 ratio without expansion is applied to the wound
(Fig. 4). On the dorsum of the hand the skin is applied
in a transverse direction. A small margin of autograft
is overlapped on the surrounding unburned skin. This
is done to assure complete wound coverage even if graft
slippage occurs during the application of the dressing.
In most instances it is unnecessary to suture the graft
in place and only Steri-Strips and tincture of benzoin
are used to fix the grafts to the wound surface. This is
very useful for securing autograft to the digits. Anti-
biotic impregnated fine mesh gauze, such as neomycin,
FIG. 1. Sequential eschar excision is performed using the Humby is applied over the mesh graft followed by a layer of
Knife. Kling,® fluffed Kerlixg and another layer of Kling
bandage. Finally, the arm, hand and fingers are splinted
this agent has a two-fold purpose. 1) The eschar is with a polyurethane pad or plaster-of-paris. All ex-
"hardened" and becomes dry making the technique of tremities are elevated for the first six postoperative
excision easier. The application of other topical anti- days. The dressing is removed on the third postopera-
microbial agents softens the eschar making the surgical tive day in order to inspect the wound for graft "take."
procedure more difficult. 2) The application of this The hand and fingers are then rewrapped until the sixth
agent imparts a "transparent" appearance to the postoperative day at which time physical therapy is
eschar. Thrombosed dermal blood vessels are more begun.
easily identified making it easier to differentiate be-
tween deep dermal and third degree portions of the Results
wound. Of the 60 patients, 12 had unilateral and 48 bilateral
Tangential excision is performed using a Humby hand excision. A 100% autograft "take" occurred in all
knife and/or the Goulian-Weck dermatome (Figs. 1 and but ten hands. Immediate complications were minor
2). The former instrument is ideally suited for excision
of eschar on the dorsum of the hand and the latter for
excision of eschar on the digits. The instruments are set
to .008 inch depth and sequential eschar excision car-
ried down to fine punctate bleeding or until a "shiny"
dermal layer in the wound is visible (Figure 3).3'4
Minimal instrument pressure against the burn wound
assures sequential excision of even depths of tissue.
Too great a pressure results in digging into the burn
wound causing needless excision of viable dermis or in-
advertent full thickness wound excision. Extreme care
must be exercised when excising burns over the dorsum
of the digit because of the close proximity of the under-
lying extensor hood and tendon. It is important to tan-
gentially excise the deep dermal burn in the web spaces,
because hypertrophic scarring and webbing of the
dorsum of the interdigital spaces may occur at a later
date. Once the level of fine punctate bleeding is reached
in the wound, hemostasis is obtained by the topical FIG. 2. The Goulian-Weck dermatome is ideally suited for eschar
application of thrombin in solution, warm laparotomy excision over the digits.
VOl. 189.o NO. 2 DERMAL HAND BURNS 149

FIG. 3. An adequate depth

of excision is identified
when fine punctate bleed-
ing is noted.

and included partial graft loss due to local wound sepsis One long-term complication noted in a few patients
in three hands and dislodgement of graft secondary to has been webbing of the dorsal interdigital web spaces.
improper postoperative splinting in seven hands. Spon- The early institution and constant wearing of the pres-
taneous re-epithelialization occurred in all hands with- sure fitting gloves has softened and remolded the im-
out the need for reautografting. mature scar making surgery unnecessary except in one
Physical therapy was initiated on the sixth post- patient who required scar release between the fourth
operative day. This consisted of active range of mo- and fifth digits three years postoperatively.
tion, coordination and strengthening exercises. Hands Of the 60 patients who had early tangential excision
were not routinely splinted at night. By the tenth post- with immediate autografting, 11 patients were ex-
operative day, full range of motion had generally cised after the seventh postburn day. The delay in ex-
returned. cision was for the following reasons: intervening week-
Patient follow-up has ranged from three months to end-five patients; burn wound cellulitis-four pa-
three and one-half years. On discharge from the
hospital all patients were followed biweekly in the
physical therapy department and weekly in burn clinic
and eventually at three month intervals in burn clinic.
This assured continued proper physical therapy and on-
going evaluation of both hand function and cosmetic
appearance. All patients were treated with "tube"
stockinette prior to their hospital discharge and within
six weeks of surgery, all patients were wearing Jobst®
gloves. No patient has required resurfacing of the
previously skin grafted area because of hypertrophic
scarring. Although the "mesh" appearance of the skin
is somewhat unsightly for several months after surgery,
it becomes less apparent with time and has been almost
undetectable two years after autografting (Fig. 5).
Range of motion has remained excellent and many of
the patients who were actively employed prior to FIG. 4. Mesh autograft at 1½: 1 ratio without expansion is applied
surgery have returned to some type of work status. on a freshly excised deep dermal burn.
 HUNT, SATO AND BAXTER Ann. Surg. * February 1979
150
of no consequence, but this has disastrous conse-
quences in the upper extremity. As long as the wound
remains open, tissue edema persists. The combination
of tissue edema and immobilization in the hand and
digits, particularly of the interphalangeal joint, pro-
motes. small joint stiffness.8 In all patient populations,
prevention of proximal interphalangeal joint stiffness is
of paramount importance.
Non-operative management of deep dorsal hand
burns requires both continuous splinting and eleva-
tion of the extremity for a prolonged period of time.
This imposes additional nursing and physical therapy
management which can be eliminated by early surgical
excision and autografting.
FIG. 5. Two years after excision and autografting. Mesh pattern is Although topical antimicrobiol agents are used to
almost imperseptible. control the bacterial population of the burn wound, in-
fection still continues to be a threat to patient survival.
tients; associated complications, i.e. -inhalation In small burns systemic sepsis is unusual, but local
injury-two patients. Surgical procedures at this wound sepsis can cause conversion of second degree
hospital are not performed on either Saturday or Sun- burn to a deeper depth or even a full thickness injury.
day unless they are considered a surgical emergency. Early closure of the burn wound prevents this com-
In all cases the delay in surgical excision did not ad- plication.
versely effect either the surgical technique, graft Infectious complications prior to wound excision
"take" or ultimate hand function. have been minor. In most cases, bacterial coloniza-
Seven patients had immediate tangential excision tion of the wound was easily controlled preoperatively
with application of homograft. Autografting was then with topical antimicrobial agents. Several instances of
performed three to seven days after the initial opera- burn wound cellulitis did occur prior to the fifth post-
tive procedure. These patients were treated early in this injury day. Burn wound cellulitis has even appeared
series and this technique has since been abandoned in as soon as six hours after a previously normal wound
preference of immediate autografting. examination and generally takes from three to five days
There were two deaths among the 60 patients-a to resolve. Cultures of the wound were most often posi-
20-year-old man with a 68% burn and a 52-year-old man tive for Staphylococcus aureus, coagulase positive. In
with a 49% burn. Each patient had successfully under- most instances systemic signs and symptoms of infec-
gone tangential excision and autografting of the hands tion are minimal. The patient is usually febrile and
but succumbed to bronchopneumonia. examination of the wound reveals the surrounding un-
burned skin erythematous, warm and painful to touch.
Surgical excision is always delayed until the cellulitis
Discussion completely resolves with appropriate topical and
The ultimate goal in treating any thermally injured parenteral therapy.
patient is early closure of the burn wound." 7'10 Spon- Early closure of dorsal hand and finger burns has a
taneous reepithelialization of a deep dermal burn is significant nutritional and psychological impact on the
equivalent to delayed closure of the wound. It is not patient's recovery. Early utilization of hands for feed-
unusual for this type of wound to take three to five ing purposes is without a doubt a great advantage and
weeks to heal. Certain anatomical areas of the body, the patient becomes less dependent on hospital person-
such as the back and buttocks, are of low priority for nel and more dependent upon himself.
excision because of their posterior location and the The ultimate cosmetic appearance of the resurfaced
generous thickness of the dermis, and therefore lend hand is of primary concern to the injured patient. Al-
themselves to conservative therapy. It is inadvisable though our follow-up is somewhat short, at the present
for a number of reasons to treat deep dermal burns of time significant hypertrophic scarring has not been a
the dorsum of the hands and fingers conservatively. complication in any patient and reconstructive plastic
Early wound closure of the burned hand has its surgery has been unnecessary for cosmetic reasons.
greatest asset in accomplishing early mobilization. An The timing of burn wound excision is of utmost im-
open wound is painful and immobilization lessens portance. In large cutaneous burns, hemodynamic
wound pain. In many anatomic areas of the body this is stabilization cannot be adequately achieved until at
Vol. 189 . No. 2 DERMAL HAND BURNS 151
least the third postburn day. In addition, pulmonary though the mesh appearance of the skin is apparent for
complications such as inhalation injury, a contraindica- the first six months post grafting it becomes less ap-
tion to surgical excision, may not be manifest until parent and by two years postautografting is almost un-
several days after the burn. The pathophysiology of a detectable. It is important to harvest split thickness
deep dermal burn was initially described by Sevitt9 skin grafts at .010-.012 inches in order to obtain best
and later Jackson, et al.2 A viable margin of tissue, the cosmetic results. Thick pieces of meshed skin are un-
zone of stasis, surrounds the nonviable burn tissue or sightly on healed deep dermal burns and the mesh ap-
the zone of coagulation. Tangential excision of deep pearance remains evident indefinitely.
dermal burns must be carried down through the zone of Recently, tangential excision has been carried out
coagulation into the zone of stasis. Fine punctate bleed- with total circulatory occlusion of the extremity using
ing from the wound surface identifies the zone of stasis. pneumatic tourniquet. Prior to inflation of the tourni-
Hypoperfusion, vasoconstriction and sludging of blood quet, sample areas of the burn wound are tangentially
occur in the early postburn period and if excision is excised in order to identify the depth of the deep dermal
carried out too soon after the injury, some viable tis- injury. The arm and hand are not elevated prior to in-
sue will needlessly be excised in order to arrive at a flating the tourniquet so that blood will be trapped in
level of punctate bleeding indicative of an adequate patent dermal vessels. Identification of the proper level
depth of excision. When excision is delayed until the of tangential excision is ascertained when a vascular
third postburn day, demarcation between the zones of "ooze" or a "white moist surface in the dermis" is
stasis and coagulation is clinically more readily identi- identified.4 Excision must obviously be carried deep to
fiable. any thrombosed dermal vessels. With the tourniquet
Delaying burn wound excision until tissue edema has still inflated, meshed autograft 1½/2: 1 without expansion
resolved is unnecessary. Even though extremities are is applied to the wound and an occlusive dressing is
continuously elevated during the first week postinjury, applied. Careful attention must be directed at applying
edema still remains. The presence of tissue edema has a tight enough dressing to maintain uniform pressure
not caused any technical difficulties in excising deep over the entire excised wound bed, yet insufficient
dermal burns. In fact, tissue edema makes the burn pressure to cause venous outflow or arterial inflow oc-
wound contour more even allowing for easier excision. clusion. Using this technique, blood loss has been
It is mandatory that any tangentially excised deep greatly reduced and greater than 30% of the total body
dermal burn wound be immediately covered either with surface burned area can be excised at one operative
autograft or some type of physiologic dressing; other- procedure.
wise, the exposed surface becomes necrotic and a
pseudoeschar forms.6 It is our policy to immediately References
autograft all tangentially excised wounds of the hands 1. Burke, J. F., Bondoc, C. C., et al.: Primary Surgical Manage-
and fingers. Even in large burns where donor sites are ment of the Deeply Burned Hand. J. Trauma, 16:593, 1976.
2. Jackson, D. MacG and Stone, P. A.: Tangential Excision and
limited, wound coverage with autograft is the first Grafting of Burns. Br. J. Plastic Surg., 25:416, 1972.
priority. In a few patients, homograft was immediately 3. Janzekovic, Z.: A New Concept in the Early Excision and Im-
applied to the excised wound bed. In each of these mediate Grafting of Burns. J. Trauma, 10: 1103, 1970.
4. Janzekovic, Z.: The Burn Wound from the Surgical Point of
cases, considerable blood loss was associated with ex- View. J. Trauma, 15:42, 1975.
cision of 30% of the total burn surface. It was deemed 5. Labandter, H., Kaplan, I. and Shavitt, C.: Burns of the Dorsum
inadvisable to subject the patient to additional surgical of the Hand: Conservative Treatment with Intensive Physio-
therapy Versus Tangential Excision and Grafting. Br. J.
trauma and operative time needed for autografting. The Plastic Surg., 29:352, 1976.
homograft "took" and reepithelialization occurred 6. Lawrence, J. C. and Carney, S. A.: Tangential Excision of
over a period of several weeks. Unfortunately, the Burns: Studies on the Metabolic Activity of the Recipient
Areas for Skin Grafts. Br. J. Plastic Surg., 26:93, 1973.
ultimate cosmetic results were unsatisfactory because 7. Mahler, D. and Hirshowitz, B.: Tangential Excision and Graft-
early hypertrophic scarring occurred. ing for Burns of the Hand. Br. J. Plastic Surg., 28:189, 1975.
Meshed autograft at 1½2: 1 ratio without expansion 8. Peacock, E. E., Jr., Madden, J. W. and Trier, W. C.: Some
Studies on the Treatment of Burned Hands. Ann. Surg., 171:
has a number of advantages over sheet grafting. First, 903, 1970.
the mesh graft conforms to the wound surface better 9. Sevitt, S.: Local Blood-Flow Changes in Experimental Burns.
than sheet graft. Secondly, serum and blood can escape J. Pathol. Bacteriol. 61:427, 1949.
10. Wexler, M. R., Yeschua, R. and Neuman, Z.: Early Treatment
through the graft interstices without causing subgraft of Burns of the Dorsum of the Hand by Tangential Excision
collections of fluid resulting in graft loss. Third, al- and Skin Grafting. Plast. Reconstr. Surg., 54:268, 1974.