Introduction

Historical perspective

Since the days of Hippocrates, traumatic wound management has been based on the fundamental surgical principle of immediate debridement of necrotic tissue and primary wound closure. Until recently, burns have always been the exception to this fundamental principle. With the ability of topical agents to control burn wound sepsis, topical therapy dominated burn treatment. Although the benefit to the patient by way of control of burn wound sepsis was enormous, it is well to recognize that this control was at the cost of slower spontaneous formation of burn eschar and, perhaps more importantly, an unstated philosophy implying that dead tissue produced by burning must be allowed to demarcate spontaneously before removal and that wound closure by skin graft must be carried out only after the development of a clean granulating recipient bed, thus resulting in a prolonged time between injury and wound closure. The past 10 years have seen the development of safe and effective blood replacement, improved monitoring equipment and, importantly, an understanding of the nutritional requirements of the thermally injured patient. The early excision and grafting of the burn wound have dramatically changed traditional burn care; however, this change has only been accepted slowly.

Early removal of large areas of full thickness burn to reduce the mortality and morbidity associated with thermal injuries has been attempted with varying degrees of success during the past 50 years.