 We have already seen how during the early supportive care in the management of burns an accurate appraisal of the burn was made and intensive adequate systemic therapy was begun. Then during the local care phase the methods of treating burn wounds to minimize bacterial growth were demonstrated, open wound procedures and closed wound techniques were shown. This next phase of the management of burns will demonstrate the operative care of third degree burns after they have been prepared for skin grafting. In the pre-grafting period, autolisis of the necrotic tissue occurs. Removal of the necrotic tissue may be hastened by the surgeon's frequent dressing changes with gentle-debrate mount of revitalized tissue. Gradually pink flat healthy granulation tissue appears which is suitable for grafting. This granulation tissue is contaminated with bacteria. Cultures of burn wounds will consistently show microorganisms but the wound is not clinically infected. The presence of bacteria will not prevent a good take of donor skin with the exception of penicillin sensitive beta hemolytic streptococci which may be on the wound. Granulation tissue suitable for grafting develops slowly. The process requiring 20 to 30 days from the time the patient is burned. As autolisis proceeds, necrotic sloughing of the eschar occurs. The burned surface beneath the eschar is fertile ground for the growth of bacteria. The eschar may be more rapidly removed when sterile saline solution soaks are placed on the burned area and changed every three or four hours. This will soften the eschar. Mechanical debris bond at each dressing change will remove loose tissue. An alternate method of speeding this removal of eschar is surgical debris bond followed by the application of occlusive dressings which are changed every three or four days. A patient having large areas of full thickness burn is not free from the possibility of invasive infection until complete skin coverage is accomplished. After the eschar is removed and the granulating area is pink, flat, dry and free of bleeding the wound is ready for grafting. The areas to be grafted are cleansed. Then they are dried and reexamined to make certain that the wound is ready for grafting. The amount of split thickness skin required is determined and the donor sites are selected and prepared. The selection of donor sites depends on the location of the burn wound, the amount and thickness of the graft required and the ease of management of the donor site. Donor sites are generally the larger flat areas of the body such as the patient's back or his thighs. The most convenient donor sites for small burns are the anterior and lateral surfaces of the thigh on the side of the body opposite from the burn. Using sterile technique the selected donor sites for the intended autographs are first shaved. Then they are cleansed. Finally they are draped with sterile sheets. As a preliminary to removing split thickness skin from those areas where there are bony prominences such as over the tibia or on the chest or the back it may be necessary to inject sterile saline into the subcutaneous tissue with a fitkin continuous action syringe. The brown electric dermatome is the most commonly used dermatome because of its ease and speed of handling. It is adjusted to the proper skin depth. In adults this is usually between eight one thousandths and twelve one thousandths of an inch in thickness. The donor area is lubricated with sterile mineral oil. Then the surgeon applies the dermatome to the donor site and removes the split thickness graft trying always to obtain an unbroken length of skin. When it is desirable to use thick split thickness skin for grafting as when the dorsum of the hand is being grafted the lateral surface of the thigh provides the best donor site. Thinner split thickness grafts may be taken from any available part of the body. If a chronically infected area is to be grafted the chances of securing a good graft take are better if thin split thickness skin is used. The Reese dermatome can also be used but the operation is somewhat different. The skin must be cleaned with ether. Then it is covered with special dermatome glue. The dermatome with its dermatape in place should be applied to the donor site only after the surface of the skin is sticky. The desired depth of the split thickness skin as measured on the dermatome is removed by the saw-like motion of the cutting blade. The padded dermatome operates on the same general principle except that this machine cannot use a dermatape and the dermatome glue must also be applied to the drum. After cutting the graft the dermatape is removed from the Reese dermatome. The graft is separated from it and is handled in the same manner as other grafts. After the split thickness skin graft is removed it is smoothed out on a strip of fine mesh gauze which has been lightly impregnated with petrolatum. The external surface of the graft must be against the gauze. The skin graft is then ready for application to a recipient site that has already been prepared for grafting. The skin graft should be placed loosely on the wound. Then the petrolatum gauze backing is removed from the graft. In this patient the grafts are being applied in sheets which is the preferable method for the best cosmetic results and minimal scar formation. A split thickness sheet graft may be fixed in place with interrupted silk sutures. Suturing usually is used in areas where there may be mobility such as over the buttocks on the flanks or on joint surfaces. After the grafts have been applied they should be inspected to make sure there is no overlapping of the grafts and that all air bubbles and hematomas have been evacuated. With the skin graft applied the wound is dressed with fine mesh gauze lightly impregnated with petrolatum. Occlusive dressings are applied to give light even pressure and to immobilize the region. In those areas where mobility presents a hazard to a satisfactory take of the graft, fixation can be assured by means of stents. Heavy interrupted silk sutures are inserted around the periphery of the grafted area. After placing a bulky pressure dressing against the fine mesh gauze that covers the graft, the ends of the silk sutures are tied over it to form a secure pressure dressing. For wounds in non-mobile areas, fluffs and pressure dressings without stents will suffice to maintain fixation of the skin graft. In grafting a burned hand it is particularly important that the fingers be dressed to maintain the functional position. Here the surgeon demonstrates proper positioning by placing fluffs in the palm to support each of the metacarpophalangeal joints and each of the interphalangeal joints in about 60 degrees of flexion. The wrist is slightly extended and held in position with fluffs. The thumb is abducted but maintained in a curvature of opposition. Each of the fingers is separated by fluff packing to prevent maceration and to aid immobilization. The fingers are held in their positions of flexion by placing a number of gauze fluffs over them. Then the outer dressing of pads is snugly closed to maintain the position and secure immobilization. The dressing is held in place by a semi-stretchable gauze roll which maintains a light even pressure. In patients with burns covering a large area of the body surface it may not be possible to cover all the burned areas with autographs. In such instances the autographs should be applied to priority areas as indicated by the red areas on this chart. These areas comprise the head and neck, the hands, the axilla, the regions of the major joints of the body and the buttocks. The remaining areas to be grafted are then covered with homograph skin. The homographs may be taken from a living skin donor or from a cadaver. The same preparatory procedures and rigid sterile precautions used in obtaining autographs must be emphasized regardless of the origin of the homographs. Donors who have malignancies, contagious diseases or skin diseases should not be used. Cadaver homographs must be taken within six hours after death of the donor. Race, sex and age are not important considerations. Homographs may be applied immediately after they are taken. If immediate grafting is not possible the homographs should be stored by placing them on petrolatum gauze strips, folding them into petri dishes after which they are protected from bacterial growth by adding an aqueous solution containing penicillin, one million units and streptomycin, one half gram. The petri dishes are sealed with tape and labeled as to origin and date after which they are refrigerated at temperatures of approximately 38 to 42 degrees Fahrenheit. The sooner a homograph is applied to the recipient site after it is obtained the greater will be the possibility of a complete take. However very satisfactory takes have been secured from homographs stored for as long as 15 days. When applied to a burn wound a homograph should provide a physiologic covering for periods of 21 days or longer. During this time a patient's own donor sites may be healed sufficiently to provide a second crop of autographs. As the homographs separate from the granulating surface they are replaced with the patient's autographs until the wound is covered with the patient's own split thickness skin. Sheet autographs are preferable for covering granulating burn wounds. Often however when a large area of granulating tissue must be grafted with a limited amount of autographed skin a larger area can be covered simply by cutting the sheet autographs into postage stamp size and applying them to the granulations. When this postage stamp method of grafting is used the individual pieces of grafts should be placed with not more than one half to one centimeter of uncovered area existing between the edges of the postage stamps. As the graft takes the uncovered interstices between the postage stamp grafts will epithelize secondarily. The same precautions are taken to immobilize postage stamp grafts as are taken with lay-on sheet autographs except that no sutures can be used. Autograph donor sites are managed by the exposure method. As soon as the graft has been removed the bleeding area is covered with one layer of dry fine mesh gauze. Then laparotomy tapes wetted with warm saline solution are placed over the site. The tapes are covered with a bath towel to help retain the heat. These procedures help to stop the oozing of blood from the donor site. The wet tapes and towel are permitted to remain in place while the skin graft is applied to the recipient area. When the grafting procedure is completed the laparotomy tapes and towel are removed from the donor site leaving only the layer of fine mesh gauze over the donor area. The donor site is then exposed to the air and allowed to dry. The donor area with its layer of fine mesh gauze should dry within 24 to 48 hours leaving a coagulum over the entire area of the wound. This coagulum in itself is an ideal dressing that will remain in place for 10 to 14 days. When the coagulum peels off the skin under it will be healed. The dressings on the grafted areas of the burn wound are first changed three or four days after grafting. The area is gently cleansed then the silk sutures are removed. Hematomas and seromas are also evacuated. Remaining necrotic tissue is debrided. The wound is then redressed. Care is taken to maintain immobilization of grafted areas in the region of joints. At the sixth post grafting day the grafted area is again dressed. Usually it is possible to leave the grafted area exposed at this time. After the second post grafting dressing change small granulating areas which remain when the large dressing is removed are covered with patches of dry fine mesh gauze. This type of dressing aids epithelization. If these areas are not larger than one centimeter further grafting is not usually required. The physiologic requirements of the patient must be maintained during the post grafting phase. It must be encouraged to take oral nutrition and dietary supplements high in protein. Vitamin should be added to his diet. Patients having burns of major extent generally receive postoperative antibiotics until skin coverage is complete. It is important to maintain the hemoglobin at about 15 grams and the hematocrit at about 45 to obtain a good graft. Therefore it may be necessary to administer whole blood replacement therapy. A patient is given adequate analgesia during the early postoperative phase. Emotional factors that may affect his recovery are determined and treated by the medical and nursing staffs. When the dressings are discontinued on the sixth to the ninth day following grafting physical therapy is undertaken so that the patient may regain mobility of the joints and maximum functional use as soon as possible. Early adequate resuscitation and meticulous initial local care followed by the removal of eschar and the development of good granulation tissue allow for early skin grafting. This aids the restoration of normal physiology, positive nitrogen balance, more normal joint function, less severe cicatrix formation and fewer psychological sequelae. The seriously burned patient will require the use of autographs from properly selected donor sites or the use of homographs where a sufficient autograph is not available. When applied either as cheat grafts or as posted stamp grafts using all the precautions to minimize the possibility of a poor take including the use of massive occlusive dressings or stent dressings on the grafted area and when the patient's physiologic functions have been adequately supported the burn patient should be ready on the sixth to ninth day post grafting to begin physiotherapy. The final rehabilitation phase of the management of his burns.