In this short video, we will be demonstrating basics of burn wound excision. We will start with traditional tangential excision using the clinical endpoint and bleeding to determine viability of our wound bed. This patient was admitted following a deep chemical burn to the right leg. Using a weck blade, tangential excision is performed along a representative portion of the eschar. As you can see, the anterior portion of the wound has brisk bleeding from the wound bed, while posteriorly there is no bleeding and thrombose vessels are present, suggesting additional passes will be required to adequately prepare the wound for grafting. Next, we will focus on tangential excision under tourniquet control. The benefit of this technique, as well as those that incorporate vasopressor tumescence, are significant reductions in blood loss. However, this requires an alternative clinical endpoint other than bleeding to determine wound bed viability. We utilize the three Ps mnemonic, which stands for one, pearly white dermis with the absence of hemorrhagic staining, two, pale yellow fat, again with the absence of hemorrhagic staining, and three, the presence of patent blood vessels. This will demonstrate our typical workflow in a patient who sustained deep flame burns to the left lower extremity. Prior to inflating the tourniquet, we carefully examine the burns for areas that will heal without excision and grafting. Methylene blue is used to mark any deep areas, as everything will appear pale when the tourniquet is inflated. Extremities are are exsanguinated using an Esmark bandage, and the tourniquet is inflated. Weck plates are used for the tangential excision, and we examine our wound bed after each pass. Here we see pearly white dermis and pale yellow fat. However, anteriorly there is a section of hemorrhagic staining that will require further debridement. A patent vein is visible approximately. We continue our debridement of this section and carefully note the clinical endpoints using the three Ps. Based on what we see here, the anterior border will require additional passes with the wet blade to ensure a suitable wound bed for grafting. This is a different patient undergoing tangential excision of the left dorsal foot under tourniquet control. Again, we see pearly white dermis and on closer inspection an example of a small patent blood vessel suggesting that this wound bed is viable. We will briefly touch on fascial excision. This is used in cases of very deep burns, burn wound sepsis, or in unstable patients due to the speed of this technique in reductions in blood loss. Using either sharp dissection or monopolar cautery, the eschar is elevated along the level of the superfascial plexus. This image demonstrates the end result of a fascial excision from a chemical burn that extended through the subcutaneous layer.

burn wound excision

tangential excision

tourniquet control

fascial excision

Weck blade