Deep partial thickness and full thickness circumferential or near circumferential burns of the neck, chest, abdomen, or extremities can cause serious local or systemic complications and need surgical release of the burn eschar to relieve obstruction or high pressures and restore perfusion.

• Circumferential burns of the neck can cause airway obstruction.

• Circumferential burns of the chest can cause respiratory compromise with increased peak inspiratory pressures, hypoxia, and hypercapnia.

• Circumferential burns of the abdomen can cause intra- abdominal hypertension and abdominal compartment syndrome.

• Circumferential burns of the extremities can cause muscle compartment syndrome.

Deep partial or full thickness circumferential extremity burns require prophylactic escharotomy.

Near circumferential extremity burns require frequent neurovascular checks to assess for need of escharotomy. Worsening neurovascular exam or pressure measurement >30 mmHg should prompt urgent escharotomy of the affected extremity.

In severe burns requiring massive fluid resuscitation, abdominal or extremity compartment syndromes may develop independent of circumferential burns. It is important that these high-risk patients are monitored closely and decompressive laparotomy or extremity fasciotomies are performed timely in the appropriate cases.

Electrical burns or burns associated with crush injuries may require fasciotomies, in addition to escharotomies, to restore adequate perfusion.

Deep partial or full thickness skin wounds, with an underlying vascularized bed, may be closed by autologous skin grafting, especially if healing by contracture would lead to prolonged healing time or functional or aesthetic deformity. Split thickness skin grafts (STSGs) are used most often for large wounds. Thin (0.06–0.010 in.), intermediate (0.010–0.013 in.), and thick (>0.014 in.) split thickness grafts can be harvested. Thinner grafts survive more reliably on a less vascular bed and have faster donor site healing; however, thinner grafts contract more than thicker grafts and the esthetic results are inferior. Most STSGs are of intermediate thickness, 0.012 in. Thinner grafts (0.010) should be considered in children and the elderly due to their thinner dermis.

STSG donor sites heal by re-epithelialization with proper wound care. The lateral thigh or back are the most common donor sites, although STSGs may be harvested from nearly any uninjured anatomic area, including buttocks, abdomen, scrotum, and scalp.

Meshed STSGs can be expanded and require less donor site than sheet grafts, but contract more and the esthetic results are not as good. Sheet grafts are used in children or in areas where contracture is unacceptable.

Full thickness skin grafts have little role in acute wound closure. These are reserved for delayed reconstruction of critical areas, such as the hands and face.

Meticulous technique is important for graft success, and includes hemostasis, placement of dressings, and adequate postoperative immobilization.