Covering the massive burn : a case series and review of the literature

• Published in: Wound healing southern Africa 2020-08, Vol.13 (1), p.22-26
• Main Authors: Den Hollander, D, Andreone, A
• Format: Article
• Language: English
• Subjects: Burns; Skin & tissue grafts; Wound healing
• ISSN: 1998-8885; 2076-8893

The term massive burns is used to indicate burns that cannot be covered by the patient's own skin by a single harvesting. Massiveburns therefore are a subclassification of major burns (i.e. burns > 25% TBSA) and are typically managed in a tertiary burns centre.They have been variously defined as burns extending over more than 30%,1,2 35%,3 40%4 and 50%5,6 of the total body surface area(TBSA). As 20% of a patient's body surface area (such as the face, hand, feet and perineum) is not suited to provide donor sites, amaximum of 40% TBSA can be covered with the patient's own skin, and therefore it makes most sense to define a massive burn as aburn over 40% TBSA. Massive burns provide a number of treatment challenges. The large amounts of fluids required to resuscitate these patients puts them at risk for oedema formation in the tissues, burn bound progression and compartment syndromes. Although early total excision has been suggested as the standard-of-care in highincome environments, this is associated with a massive onslaught onto the patient's physiological reserves requiring resources that are scarce in middle- and low-income countries (LMICs). Many units under these circumstances practise a staged-excision approach, but this may be associated with a higher sepsis rate. When the patient survives the initial resuscitative stage, the question arises how to cover the burned areas. Although skin is often meshed to enlarge it, it should be appreciated that harvested skin undergoes primary contraction, decreasing its area by 10-20% in a split-thickness skin graft (SSG) and 40% in a full-thickness skin graft; the result is that a 1:3 mesh of an SSG only covers 1.8 x the original donor area. Larger expansion rates (1:4 and more) leave large interstitial areas that need to be covered by a temporary skin substitute, such as cadaver skin or a dermal substitute, to prevent them drying out, while the interstitial areas re-epithelialise. Principles for excision of massive burn wounds, such as early total excision versus staged excision, and the order of areas excised in each option are well covered elsewhere8 and will not be repeated here.