Clean wounds minimize infection rate, reducing tissue reaction and controlling tissue environment which later resulting in finer scarring. Skin grafting helps closing larger wound area and avoiding prolonged wound epithelialization that risking to fibrosis closure and scarring. Several studies report the benefit of an early wound excision in terms of shorter hospital stay, lower wound infection rate, and reduction of postburn metabolic changes. Enzymatic debridement has been shown to be an effective tool for early eschar removal and in addition reduces the need for autografting of the debrided burn wound with a relatively high level of evidence (level of evidence 2). Wound debridement by means of hydrosurgery is more precise compared to conventional wound excision and preserves viable dermis, but a positive effect on wound healing or scar formation could not been shown (level of evidence 2). Furthermore, rarely reported techniques comprise larvae therapy, debridement by laser, and other technical adjuncts, but the level of evidence is limited (level of evidence 4 / 5)

Thank you a lot for your valuable answer and so i mean that when we handle and manipulate the burned tissue and underneath in bizarre direction is this handling and removing the dead tissue affect positively on disfigurements of tissues post wound healing and thank you again

very good question. let me give a response. as per my experience, the direction of debridement of dead skin does not affect the appearance after healing. the quality of care after the debridement that affects the appearance after the wound has healed. good wound care, facilitating the optimal wound healing process.

Thank you dr Sodiq Kamal for your interest and response to question

Dear Doctor

Go To

Burn Debridement, Grafting, and Reconstruction

Jordan A. Anyanwu; Renford Cindass. (2023)

StatPearls [Internet]

"Skin Anatomy and Burn Depth

The total body surface area (TBSA) of the burn and burn depth are the best predictors of morbidity and mortality and determines the treatment steps. Superficial (first-degree) burns are defined as burns to the epidermis and usually cause minimal damage and no blisters.

Burns that penetrate the dermis are partial-thickness burns (second-degree), and depending on the depth of penetration, partial-thickness burns further characterize as superficial partial-thickness or deep partial-thickness.

Full-thickness (third-degree) burns penetrate completely through the dermis and hypodermis, leaving a leathery and dry appearance to the skin.

Subdermal burns affect the layers beneath the cutaneous layer to include adipose tissue (fourth-degree), muscle (fifth-degree), or bone (sixth-degree). Surgical management and possible reconstruction are necessary for these burns.

Debridement

Upon presenting, the patient must undergo hydrotherapy or "shower" to have all devitalized tissue debrided, which is usually performed by the nursing staff. This process allows for the full extent of the burn to be visualized to determine an accurate %TBSA affected. When encountering a blister, it is best to un-roof it. If left intact, the blister becomes a potential source of infection, increases healing time, and negatively affects patient comfort and mobility. Additionally, blisters may hide deep partial-thickness burns underneath.[1] Of note, only second-degree burns and above are included in the calculation for %TBSA affected.

Early excision and grafting of the burn, noted as post-burn days 2 through 12, is the most important operation during the patients' hospital course. Early burn debridement is vital to the overall survivability and outcome of burn patients. Eschars and blisters need to be excised and/or opened as soon as possible to cease the inflammatory cascade causing secondary damage. The burned and dead tissue of partial-thickness and full-thickness burns create an opportunistic environment for gram-positive cellulitis to occur and leads to the sequelae of the wound burden, including slow healing time, physiologic impairment, contractures, and functional deficits. When burn patients undergo early excision and grafting, there is a decrease in the length of stay and faster healing time.[7][3][1] The delay of 24 to 48 hours before proceeding to the excision and grafting allows for the resuscitation and correction of physiologic derangements to optimize outcomes as well as providing time for the cells in the zone of stasis to become necrotic or demonstrate viability.

Logistical planning is necessary to determine what burns require excision and what areas are potentially useful as a graft donor site. The order of excision is dependent on the surgeon, but the goal is to safely excise and debride the largest surface areas first, such as the anterior or posterior trunk or large areas on the extremities. The size of the primary excision largely depends on the amount of available autograft or skin substitute, as it is essential to cover the excised and debrided areas. After removal of the burn eschar, the wound is open to the atmosphere, and the protective nature of the skin is compromised, which can allow for invasive infections and extensive fluid losses resulting in electrolyte disturbances and loss of oncotic pressure secondary to protein loss.[1] Generally, no more than 40% TBSA is excised at one time to prevent excessive blood loss and allow for complete coverage with autograft. For cosmetic areas and functional areas, excision should be performed at least within 7 to 14 days to improve outcomes.[8]

Surgical debridement is the gold standard of burn debridement and can be performed using a variety of tools. This process removes the necrotic tissue and foreign debris, which effectively decreases the bacterial load and allows for the excised skin to be cultured (if necessary). Surgical excision with the use of surgical knives such as the Weck/Goulian knife and the Blair knife has been the mainstay for surgical debridements. Large %TBSA and areas involving mixed partial- and full-thickness burns are best served by the use of the surgical knife technique for faster and more efficient debridement, which allows for precise and accurate preservation of healthy surrounding tissue allowing better wound healing and less scar formation.[8]  Difficult areas to debride are contoured areas (e.g., inter-web spaces of the hands and feet), thin areas (face and dorsum of the hands), and edematous areas secondary to fluid resuscitation.[9]

One of the most critical aspects that affect the cosmetic outcome is dermal preservation.[7] Tangential excision of burned tissue involves unroofing the burn eschar and debriding the dead tissue layer by layer until encountering healthy bleeding tissue. This technique has improved overall morbidity and mortality because it allows for the removal of thin layers of burned tissue leaving viable tissue undisturbed.[7] This approach is opposed to a fascial excision, which is an excision of all skin elements to the subcutaneous fat/fascia. The depth of excision can be adjusted manually on the Blair knife, and preset guards are placed on the Weck/Goulian knife. Guards range from 0.004" to 0.028". The more common guards range from 0.008" to 0.012".  Early tangential excision of partial- and full-thickness burns decreases healing time, reduces patient discomfort, prevents infection, and improves overall outcomes.

Surgical knives can sometimes result in incomplete or uneven debridement leading to multiple passes and prolonged operative time and increased bleeding.[7] Blood loss during surgical burn excision is a common problem, which can be in the range of liters lost. It is vital to have multiple units of packed red blood cells and plasma type and cross-matched preoperatively. Steps can be taken to avoid excessive blood loss using tourniquets, compressive dressings, limb elevation, infiltration, or topical application of epinephrine solutions, electrocautery, topical hemostatic agents (recombinant thrombin or fibrinogen), or staged excision and grafting. All those options have important uses in preventing anemia and hemodynamic instability secondary to blood loss intra-operatively.[1][5]

There is no consensus on what tools are best for the excision and debridement of wounds; this is left up to the preference of the operating surgeon and what resources are available at each respective facility. When deciding among the various techniques and tools for burn excision, consideration should be for the quality of life, physiology of the affected area, physical appearance, and overall survival.[7]

Additional debridement techniques are listed here:

• Hydrosurgical debridement (e.g., water jet and high-powered parallel water jet tools) is a new and useful tool in surgical debridement. Hydrosurgical debridement works by forcing a narrow stream of saline under high pressure out of a nozzle, using the Venturi effect, to remove the debrided tissue. It successfully clears bacteria from the wound bed, and this technique does not create bacterial seeding deeper into the wound bed.[10] Pressure settings can be adjusted to gently debride a superficial wound and remove pseudoeschar to debride deep partial-thickness burns aggressively. This process also effectively and precisely debrides fascia and tendon but does not affect bone or hard eschar. Eschars that are deep, hard, dry, or leathery are not easily debrided and require multiple passes as well as higher pressure settings.[8][9] Proponents of this technique advocate that this does not necessitate a big or intricate surgical instrument tray, which allows for quicker set-up and operating room turnover. The selectivity of hydrosurgical debridement saves money in the operating room. It decreases the number of operative take-backs for further debridement due to the specificity and efficiency of the debridements. The tool is small enough to debride hard-to-reach locations and obtain a better contour of the tissue to allow superficial to deep partial-thickness burns to be successfully excised more efficiently. The effectiveness of hydrosurgical debridement to produce healthy bleeding wound beds is comparable to cold knife and brush techniques but with better speed and precision. The advantages of hydrosurgical debridement are the ease in learning the technique and the reduction of total debridements, which lower operative costs. However, as previously stated, full-thickness burns will still require cold knife excision.
• Autolytic/Enzymatic debridement involves the use of proteolytic enzymes and agents that digest the burned and dead tissue. This process is limited in its use because it has a slower healing time and results in significant pain with dressing changes that require appropriate analgesia. The necrotic tissue is slowly debrided and can promote an invasive infection or even produce a septic inflammatory response.[8] Debridement with collagenase and papain/urea agents has shown success, but they are time and labor-intensive and not ideal in extensive TBSA burns.[8] Bromelain-based agents have some utility as they are highly specific for burn eschar. They do not penetrate the intact dermis and avoid the breakdown of healthy, viable tissue. Compared to surgical debridement, these agents have been found to decrease the total number of debridements, time to healing, and the need for autografting. Enzymatic debridement with bromelain-based agents allows for faster re-epithelialization and selective debridement down to bleeding, viable tissue. Another potential advantage for its use is the avoidance of escharotomy to avoid compartment syndrome caused by circumferential burns found in one study.[11] Financially, these topical debriding agents allow for a reduction in overall cost when used for burns less than 15% TBSA. At over 15% TBSA, the savings were no different than other types of debridement. Some of the disadvantages of using enzymatic debridement include an associated local redness to the treated area, which can be a cosmetic concern to some patients. There is also increased pain with the application and removal of the enzymatic agents when done bedside with no anesthesia.[7]
• Mechanical debridement can be utilized with frequent moist to dry dressing changes. This process involves placing a moist dressing over the affected area and then removing the dressing when it is dry. This technique removes the dead tissue adherent to the dressing but causes significant pain and can be nonspecific in removing surrounding healthy tissue.[8]
• Sterile maggots can be used in biologic debridement as they will only consume the necrotic wound tissue. This technique is a successful and effective strategy; however, there is hesitancy and apprehension from patients and healthcare staff when using this technique that limits real-world applications.[8]"

Thank you a lot prof dr Sundus Hantoosh and for prof dr Stephan C for your recommendations of the question

But Dr Sundus is there is any study about the relation between debridement technique steps which include bizarre removal of dead burned tissues on subsequent cosmetic appearance ?

Thank you dr sundus for your recommendation

Also i specifically ask is is there a relation between mechanical debridement and bizarre removal of dead burned tissue on cosmetic appearance and can we follow the removal in one direction and observe if this has a relation with cosmetic appearance or not post burn wound healing ?

Thank you a lot prof dr stephan for your recommendation