Skin Grafting in Burns

Chester N. Paul, MD, FACS

As the art and science of skin grafting developed it became clear early on that allograft skin, while a good temporary burn covering, was not a long-term solution to treating burns. The same is true of attempts at xenografting. Immune reactions were not found to be the cause of allograft rejection until the 1940s.4 As grafting of larger burned areas was undertaken, methods to provide broader coverage of the excised bed were needed. Often the amount of normal skin available to act as graft donor sites was a limiting factor. The concept of “meshing” the skin graft to allow it to stretch for greater coverage was not new. A hand held device for this very purpose was devised and reported by Lanz,14 a German surgeon, as early as 1907.4,14 Improvements in these hand held devices followed, but of these, the hand cranked double roller graft mesher developed by Tanner and Vandeput15 was the most significant. Current graft meshers function in a remarkably similar fashion today.

The timing of surgical intervention and grafting in burns had previously been an area of spirited debate. Burned tissue was originally allowed to slough off due to auto digestion, sub-eschar infection, and bacterial digestion severing the attachment of dead tissue to the subjacent viable tissue. Subsequent skin grafts were then applied to the remaining granulating wound bed. Major burns have been plagued with invasive infections and malnutrition as the eschar was allowed to slough throughout history. Early excisions of dead burn tissue with immediate closure, application of dressings, or grafts had been advocated as early the late 1800s.

Remarkably, this technique did not become the standard of practice in the burn community until the latter 20th century. Many authors promoted the concept of excising dead tissue followed by application of skin grafts, but it was left to Zora Janzekovic to present an integrated concept of early burn excision followed by immediate skin grafting. Janzekovic presented her revolutionary work in the mid 1970s when she published her technique of shaving off layers of dead tissue until a viable base of living tissue was reached, which was followed by immediate skin grafting. The shaving of multiple thin parallel layers of the burn until healthy tissue is reached is known as tangential excision.16–18 While the term “tangential excision” is not technically accurate, it is the term most often used in current surgical literature. This original presentation solidified the concept of early excision and grafting in the burn community. The efficacy of this technique was confirmed in a groundbreaking study by Heimbach.19 This seminal study confirmed that early excision and grafting of burns lower costs, shortened hospital stays, and lowered burn mortality—a goal that has been sought since burn care was first undertaken.20 In the burn community today, the principle of early excision and grafting of very deep to full-thickness burns is considered the standard of care. Another appealing approach to autologous skin coverage of excised burn wounds surfaced in l979. In that year Green, Kehinde, and Thomas21 published their success in growing epidermal cells in tissue cultures.

This technique has been further refined and it is now possible to grow large sheets of the patient’s epidermal cells in tissue cultures. These cells can then be transferred to the prepared burn wound to provide autologous epidermal coverage. Although a fascinating approach to burn healing there have been many clinical draw backs and this technique has not found universal acceptance in the burn community.21


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