Tangential Excision of Burns 
Cassidy A. Muir, Peter Stafford, Goran Jovic, Deepak K. Ozhathil 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
Where resources permit, early burn excision 
for deep partial and full thickness burns and skin 
grafting is recommended. Tangential excision was 
pioneered by Dr. Zora Janžekovič through her work 
with burn patients in the former Yugoslavia in the 
1960s. Since then, it has become the standard of care 
in resource-rich settings where there may be ready 
access to blood products and general anesthesia.  In 
contrast, in resource limited settings, conservative 
management is pursued, as this is often safer for the 
patient. This approach consists of wound care until 
the burn eschar has sloughed off, leaving a 
granulating wound that can be grafted. However, in 
many cases (including the examples shown in this 
chapter) it is safer and more expedient to excise 
tissue that is clearly burned.  
Burn wounds can be excised in a tangential 
or fascial manner.  Tangential excision is performed 
most often and involves sequential excision of 
burned tissue until viable tissue is reached.  This can 
be done with a number of different surgical 
instruments.  Most commonly, sharp excision is 
performed with the Watson knife or the Goulian-
Weck blade. Progenitors of these instruments such as 
the Rosenburg, Thiersch, and Humby knives are still 
used at some institutions.  Powered dermatomes such 
as a Padgett-Hood or Brown dermatomes or 
Amalgatome can be used, as well as hydrosurgical 
dissection 
using 
a 
VersaJet, 
or 
mechanical 
debridement using a TPS Dermabrader. The latter 
techniques are especially useful on highly contoured 
surfaces such as the face and hands.  
 
Full fascial excision removes skin and 
subcutaneous tissue en-bloc down to the anterior 
fascial plane and is usually performed with 
diathermy or in combination with sharp dissection.  
This technique is reserved for deep, large, or severely 
and invasively infected burns where patients would 
not tolerate the extensive blood loss of tangential 
excision. Fascial excision is associated with 
lymphedema and contour deformities leading to 
worse functional and cosmetic outcomes. 
 
Full fascial excision removes burned tissue down to the fascia 
underneath, usually performed with diathermy or a scalpel 
blade. This technique is not further described here. Source: 
Greenwood JE et al, 
 https://doi.org/10.1016/j.burnso.2020.06.003 
 
 
The steps of tangential excision and grafting 
include:  
● Preoperative labs and assessment of the need for 
blood availability 
● Determination of area to be excised and 
positioning of the patient 
● Temperature regulation 
● Techniques to limit blood loss with excision 
● Tangential excision to viable tissue 
● Hemostasis 
● Immediate autografting or placement of skin 
substitute 
● Dressing placement 
 
Steps: 
1. Preoperative hemoglobin or hematocrit levels 
should be obtained.  Depending on the value and 
the total body surface area planned to be excised, 
blood may need to be prepared for transfusion. 
2. The area to be excised is planned prior to surgery, 
but the amount excised may change intra-
operatively due to the physiologic status of the 
patient.  When performing multiple excisions 
over the course of several days, large areas, such 
as the anterior or posterior torso, or large portions 
of an extremity are excised first, removing as 
much non-viable tissue as is safely possible.  In 
Tangential Excision of Burns 
Cassidy A. Muir, Peter Stafford, Goran Jovic, Deepak K. Ozhathil 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
cases where the patient may not be stable enough 
to tolerate excision of all wounds in a single 
surgery, many surgeons prefer to stage excisions 
in a proximal-to-distal manner, choosing to 
minimize mortality risk at the expense of 
increasing functional morbidity. The patient may 
be positioned supine, lateral decubitus, or prone 
as needed to perform the surgery.  At times, it 
may be necessary to reposition the patient 
intraoperatively to access the necessary sites for 
excision and grafting. 
 
 
 
Patient positioned prone for excision of full  thickness buttock 
burn wounds 
 
3. The burned patient’s ability to maintain their 
body temperature is altered, and it is important to 
keep the patient warm, between 36-38C.  
Uninvolved areas should be covered with 
blankets and involved areas may be temporarily 
covered with a surgical drape or a fluid warmer 
cover.  For large surface area burns, a tremendous 
amount of heat can be lost from the patient during 
the surgery. Therefore, it is essential to pre-warm 
the operating theater prior to surgery, make every 
effort to minimize unnecessary heat loss from the 
room, and closely monitor the patient’s 
temperature throughout the case. If the patient’s 
temperature deteriorates during the surgery, the 
surgeon should limit the extent of excision and 
staging operative goals over multiple surgeries, 
giving time to rewarm and resuscitate the patient.  
4. A major limitation of tangential excision is blood 
loss, and it is important to take steps to minimize 
surgical blood loss.  Studies have demonstrated 
standard blood loss of 40-80 cc per 100 cm2 of 
excised tissue.  For wounds to distal extremities, 
a tourniquet placed proximally works well. 
Compression bandages, along with hemostatic 
dressings if available, or laparotomy pads soaked 
in epinephrine solution are also useful to apply 
pressure to minimize bleeding after excision. For 
the 
torso, 
subcutaneous 
injection 
of 
an 
epinephrine solution at a concentration of 
1:200,000 to 1:1,000,000 can be used in 
combination 
with 
the 
hemostatic 
efforts 
described. Diathermy is also necessary in the 
excision of most large burn wounds, but care 
should be taken to minimize iatrogenic thermal 
injury to the wound bed.   
5. Tangential excision involves sequential passes 
with a sharp knife, removing non-viable burned 
tissue until vascularized tissue is present.  It is 
helpful to start with excision of dependent 
portions first, as these areas may be otherwise 
obscured by blood that has run down from non-
dependent areas.  Excision is facilitated by 
making the tissue taut.  For the extremities this 
can be obtained by pulling and tightening the 
tissue from the opposite side.  Penetrating clamps 
can be used to give tension.  For the torso, 
penetrating clamps and subcutaneous injection of 
epinephrine solution are particularly helpful to 
provide tension. 
Tangential Excision of Burns 
Cassidy A. Muir, Peter Stafford, Goran Jovic, Deepak K. Ozhathil 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
The excision knife is passed back and forth in 
a sawing motion, with <30 degree downward 
angled pressure and the knife gradually 
advancing forward.  While the knife has a guard, 
the depth will vary based upon the angle and 
pressure applied. Upon completion of the pass, 
the knife is angled up away from the skin as the 
back-and-forth movement continues and tissue is 
excised. It is important to excise the wound down 
to viable tissue, as leaving non-viable tissue will 
lead to graft loss, wound infection and further 
wound deterioration.  If time allows, it is possible 
to exercise a mixture of viable and non-viable 
dermis in the hopes of tissue preservation. In 
many cases, dermal preservation can salvage a 
mixed depth wound with sufficient viable dermal 
elements. This approach requires a staged return 
to the operative theater within 2 – 5 days to 
visualize and possibly excise more tissue prior to 
pursuing definitive wound closure. Excision for 
full viability is carried to diffuse punctate 
bleeding of the dermis. The deeper in the dermis, 
the larger the vessels and more spread out in 
appearance. 
 
Tangential excision of a burn wound using a Humby knife with 
the guard set to maintain a relatively uniform depth. Source: 
Sharma D et al, 10.18203/2349-2902.ISJ20192374 
 
 
 
An illustration of Dermal Preservation as described in the text. 
The Red line shows the depth of the burn. In this strategy, an 
initial tangential excision is done intentionally shallow, 
excising most of the burned tissue but leaving behind small 
“patches” shown by the Blue arrows. These can be excised 
later, resulting in better preservation of tissue.  
 
When the entire dermis is non-viable, excision is 
extended until shiny, yellow fat is obtained.  
Thrombosed vessels within the fat, and brown, 
gray or orange discoloration are signs of non-
viable tissue. 
Under tourniquet, excision of the extremities 
is carried to a white moist surface in the dermis 
or a bright yellow surface in the fat.  
Hemoglobin-stained layers of the dermis or gray 
and brown areas of the fat should be excised. 
 
Tangential Excision of Burns 
Cassidy A. Muir, Peter Stafford, Goran Jovic, Deepak K. Ozhathil 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Appearance of a full thickness burn eschar prior to tangential 
excision.  
 
 
Tangential excision with a Goulian-Weck knife, which allows 
careful excision of small amounts of tissue. Once bleeding 
tissue is obtained, excision is deep enough.  
 
 
Completed excision of a full thickness burn wound, to viable fat. 
Through careful technique, the extensor tendons, tendon 
sheaths, and other important structures have been preserved.  
 
6. Prior to tourniquet release of the extremities, 
gauze soaked with epinephrine solution at a 
concentration of 1:33,000 to 1:1,000,000 is 
applied and compression with elastic bandage 
can be used.  This is left in place for several 
minutes prior to release of the tourniquet.  Some 
prefer to place autograft prior to release of the 
tourniquet.  Any residual areas of bleeding are 
controlled with sutures or cautery as needed. 
Care must be taken to keep track of the length of 
time an extremity is under tourniquet. The longer 
the restriction of blood flow the greater the risk 
of deep venous thrombosis, compartment 
syndrome and reperfusion injury. 
7. It is not necessary to immediately place a graft 
over the excised wound bed, but if this is not 
done, a moist dressing must be placed. Paraffin 
or petroleum jelly-soaked gauze is acceptable. 
This must be changed every 3-5 days.  
8. If immediate autografting is planned, the donor 
site is prepared.  Here we briefly describe the 
technique, which is further described in the 
chapter Split Thickness Skin Grafting. The site 
may be injected with an epinephrine solution 
which helps with hemostasis and in obtaining a 
uniform graft.  Depth of the graft to be taken 
varies based upon age of the patient, location of 
donor site and area to be grafted, and amount of 
donor site available.  Often, a depth of 10/1000 
to 15/1000 of an inch is chosen (0.25-0.4 mm.) 
The surgeon should consider the amount of 
tumescence solution injected. Higher volume 
injections lead to increased moisture and delayed 
donor site healing.  
When collecting the split thickness skin graft, 
the donor site is made taut and mineral oil or 
lubrication gel mixed with water is used to reduce 
friction and facilitate gliding of the dermatome.  
A manual or powered dermatome is used to 
obtain skin.  Frequently, the skin is meshed to 
expand the graft, increasing the area that can be 
covered and reducing the risk of seroma and 
hematoma formation.  “Pie-crusting” can be 
performed by hand or with a mesher and  will 
generally provide less skin. 1:1 meshing will 
expand the skin back to its original size, 2:1 will 
expand to ~1.5x, 3:1 to ~1.9x, and 4:1 to ~2.1x 
the original size.  Unmeshed skin grafts are also 
used, though rarely, to cover small burn wounds 
on regions of the body where scar contracture 
should be minimized. Unmeshed graft is at 
higher risk of failure, from accumulation of 
Tangential Excision of Burns 
Cassidy A. Muir, Peter Stafford, Goran Jovic, Deepak K. Ozhathil 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
blood or seroma fluid that impairs apposition to 
the wound surface. The meshing ratio is chosen 
based on the amount of available donor skin as 
well as the body region the wound is located. 
 
“Meshing” of the grafted skin allows coverage of a wider area, 
although cosmesis is worse. This approach would not be 
suitable for the face. Source: By Giftrapped - Own work, CC 
BY-SA 4.0,  
https://commons.wikimedia.org/w/index.php?curid=12283501
1  
 
Face, hands, feet, neck and forearms generally 
warrant lower meshing ratios to minimize scar 
contracture and improve cosmesis. Proximal 
extremities and the thorax can tolerate higher 
meshing ratios, but will take longer to heal, leave 
diamond interstices pattern, and cause more scar 
contracture. Hemostasis of the donor site is 
obtained with epinephrine-soaked gauzes.  Once 
hemostasis is obtained, a dressing is applied. 
 
Tumescence of donor site with an epinephrine solution 
 
 
Tension assisted by penetrating towel clamps. An electric 
dermatome is being used to harvest skin in this case.  
 
 
An assistant maintains tension on the skin while a surgeon 
harvests a skin graft. A manual dermatome is being used to 
harvest skin in this case.  
 
 
Harvesting of skin with manual dermatome  
 
Tangential Excision of Burns 
Cassidy A. Muir, Peter Stafford, Goran Jovic, Deepak K. Ozhathil 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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9. The graft is secured to the wound using staples, 
sutures, or fast-drying skin glue.  Negative 
pressure wound therapy, a tie-over bolster, or 
layered dressings are used to secure and protect 
the graft. Regardless of dressing type, a non-
adhesive fine-mesh layer of some form should be 
placed first to prevent maceration of the graft and 
shearing with dressing changes. A commonly 
available dressing material is petroleum jelly 
(Vaseline ®) soaked gauze.  
 
We make our own petroleum jelly gauze by impregnating plain 
gauze with jelly in a reusable sterilizable container.  
 
 
Autograft secured with a combination of staples and sutures 
 
 
Graft over the sacral area secured with negative pressure 
wound therapy. Note also a rectal tube is being used to divert 
stool from the area.  
 
 
A “tie over bolster” dressing can be used to secure small skin 
grafts.  
 
Pitfalls 
● Hypothermia prior to or during the surgery is one 
of the most dangerous and avoidable challenges 
the burn surgeon faces. Hypothermia results in 
increased blood loss, tissue ischemia and 
markedly worsens peri-operative mortality. The 
patient’s room and the operative theater should 
be warmed to 74 -95 F (23 – 35 C) depending on 
the size of injury and the size of the patient. 
Pediatric patients can deteriorate particularly 
quickly if normothermia is not maintained. 
● Tangential excision is more challenging with a 
wound that has been treated by the exposure 
method. An eschar forms over the wound, 
limiting assessment of its depth and preventing 
easy passage of the excision knife. 
● It is important that the excision knife does not get 
snagged at the end of the blade.  This occurs if 
the end of the blade runs into tissue as opposed 
to going over it. If the end does get caught, the 
knife will not advance forward easily and can 
Tangential Excision of Burns 
Cassidy A. Muir, Peter Stafford, Goran Jovic, Deepak K. Ozhathil 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
begin to cut too deeply. Angling the blade to the 
desired depth of excision is essential. 
● If 
the 
patient 
becomes 
hemodynamically 
unstable, stop further excision, obtain hemostasis 
and allow the anesthesia team to catch up with 
resuscitation.  You may not be able to do 
everything that was planned for that case and 
need to return at a later time. 
● Positioning of circumferential wounds can be 
challenging. The use of staff to help elevate the 
extremity can be sufficient for smaller patients 
with limited posterior wounds. For larger patients 
or wounds with significant circumferential 
components, 
surgeons 
should 
consider 
mechanical assistive devices such as ceiling 
hooks, bed frames or IV poles with weights 
added to the base for support. Alternatively, 
surgical excision can be staged, with only 
anterior or posterior surfaces being approached at 
each intervention and avoiding extremity 
elevation altogether. 
● At some institutions cadaveric homograft 
(allograft) may be available. Allograft affords a 
number of different applications. It can be used 
as a temporary wound coverage after excision 
when sufficient donor skin is not available or the 
wound bed is not yet appropriate for skin graft 
application. Autograft can also be used on top of 
a meshed skin graft to protect the graft. In these 
circumstances the skin graft is typically meshed 
at a 3:1 ratio or greater and may itself be a thin or 
fragile graft (epidermal autograft.) 
● Not all full thickness burns need to be excised. 
Full thickness wounds will heal at a rate of 1 cm 
per month, and relatively small wounds (<3 cm) 
can be allowed to heal through secondary 
intention and good wound care. For this same 
reason, a skin graft may be placed within 1 cm of 
the wound edge and allowed to heal-in, rather 
than extending up to normal skin. During the two 
weeks it will take for grafted skin to incorporate, 
the wound edge will heal to meet the graft border. 
This technique relies on contraction of the 
wound, so it is not suitable for a wound that 
crosses a joint, or is otherwise located in a place 
where adjacent skin can not stretch to fill in the 
wound.  
 
This small burn across a joint probably would have healed 
spontaneously elsewhere, for example on the thigh, where 
adjacent skin could stretch as it contracted. In this case 
however, as the wound contracted, it pulled the elbow into a 
contracture. Treatment of burn contractures is addressed in a 
separate chapter of this Manual.  
 
● Small burns can also be excised primarily if they 
do not cross a joint and there is sufficient 
uninjured surrounding skin. Care must be taken 
to not close a wound edge with injured skin.  
● For patients whose burn wound size far exceeds 
their available donor site, multiple surgeries and 
repeated harvesting of the available donor site 
should be anticipated. Thin (epidermal autograft) 
donor sites taken with the dermatome at 
<8/1000th of an inch can be expected to heal 
within two weeks if sepsis is kept at bay, 
hypermetabolism is managed and the patient 
receives adequate nutrition.  
● Immobilization and activity restriction after graft 
placement should be considered on a case-by-
case basis by the surgeon. Short term restrictions 
are used to minimize graft loss through shearing 
or fluid accumulation. Longer periods of 
restriction are associated with loss of function 
and limitations in range of motion. To balance 
these risks, some surgeons will immobilize after 
skin graft application to the hands or across large 
joints for a day or two after surgery. 
Tangential Excision of Burns 
Cassidy A. Muir, Peter Stafford, Goran Jovic, Deepak K. Ozhathil 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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● The mechanism of burn can significantly affect 
the extent of full thickness injury. Chemical, 
electrical and contact burns tend to be 
predominantly full thickness injuries that can 
extend beyond the skin and commonly warrant a 
staged approach to wound closure. Flame and hot 
oil burns tend to do well with early grafting and 
wound closure. Scald burns, counterintuitively, 
tend to heal better with delayed surgical 
intervention, particularly in children. 
 
 
 
Cassidy A. Muir, MD 
Medical University of South Carolina 
South Carolina, USA 
 
Peter Stafford MD 
Centre Médical Evangélique 
Democratic Republic of Congo 
 
Goran Jovic, FRCS (Glasgow) FCS-ECSA 
School of Medicine, University of Zambia 
Lusaka, Zambia  
 
Deepak K. Ozhathil, MD 
Medical University of South Carolina 
South Carolina, USA 
 
June 2023 
 
Resource-Rich Settings 
• 
For massive burns, an number of epidermal and dermal 
skin substitutes are available. The most commonly used 
epidermal replacement is Suprathel, which is the standard 
of care for partial thickness burns in Europe. The most 
common and well known dermal replacement product is 
Integra, which is composed of a matrix of crosslinked 
bovine collagen and glucosaminoglycan, that provides a 
scaffold for vascular ingrowth. In addition, Cultured 
Epidermal Autograft (CEA) can generate a significant 
amount of skin and is invaluable in the management of 
patients with large surface-area burns. 
• 
As stated in the text, the availability of blood and blood 
products for transfusion makes large tangential excision 
much safer.  
