Burn Surgery
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Direct answer
Zora Janžeković's tangential excision — shaving a deep dermal burn in thin slices until punctate bleeding announces living dermis — with immediate grafting converted deep burns from weeks of septic waiting into planned surgery, ideally within the first 72 hours once resuscitation is stable. Fascial excision removes everything to muscle fascia for very deep or massive burns, trading contour and lymphatics for speed and blood economy. Closure comes from split-thickness autograft, meshed when donor skin is scarce, with biological and synthetic bridges — amniotic membrane, Biobrane, Integra, cultured epithelium — covering the gap when autograft must wait. The disease being operated on is burn wound sepsis, definitively tested by the burn wound biopsy.
What you must remember
- Tangential excision ends at viable dermis — punctate bleeding and a shiny, wet surface; fascial excision sacrifices everything down to fascia and is reserved for full-thickness or very extensive burns.
- Early excision within the first week (within 72 hours in many units) reduces infection, blood loss and mortality in major burns.
- When skin is short, grafting priority runs face, hands and joints first, trunk last; meshed autograft at 1:1.5 or wider stretches the harvest.
- Burn wound sepsis is defined by quantitative biopsy — more than 100,000 organisms per gram with invasion into unburned tissue on histology; clinically, focal black discolouration, unexpectedly rapid eschar separation and conversion of partial- to full-thickness wounds warn of it.
- Topicals in one line each: silver sulfadiazine (transient leucopenia, painless); mafenide acetate (penetrates eschar, painful, carbonic anhydrase inhibition causing metabolic acidosis); silver nitrate 0.5 per cent (no eschar penetration, leaches sodium, potassium and chloride).
- Escharotomy incisions follow midlateral limb lines, avoiding the ulnar nerve behind the medial epicondyle, the radial nerve at the wrist and the common peroneal nerve at the fibular neck; the chest needs bilateral anterolateral releases crossed by subcostal incisions.
- Integra, a bilaminate dermal regeneration template, sits for about three weeks while a neodermis forms beneath its silicone sheet, after which a thin autograft is placed on top.
- Cultured epithelial autografts take roughly three weeks to grow from a biopsy and remain fragile; amniotic membrane, cheap and freely available, remains the workhorse biological dressing in many Indian burn units.
The first week of a 35 per cent flame burn
Day zero is resuscitation and airway: the Parkland prescription written, the burn mapped by depth and area, including the back. Days one and two belong to intensive care — the formula titrated to urine, topical agent applied daily, enteral nutrition started early, and theatre booked rather than awaited. Day three is the operation: tangential excision of the deep dermal burns of trunk and arms under tourniquet where possible, slice by slice until punctate bleeding, because tangential blood loss is real and easily underestimated; the circumferential full-thickness forearm burns that needed escharotomy on day one are now excised to fascia, where nothing viable remains. Harvest comes from both thighs, meshed 1:1.5, applied with staples and bolster dressings; face and hands take priority for sheet graft. A wound biopsy for quantitative culture precedes excision. The week then belongs to dressing discipline, splinted physiotherapy and hypermetabolic feeding — resuscitate, prepare, excise, graft, rehabilitate, each step examinable.
Old habits the exam punishes
"Wait for the eschar to separate" was pre-Janžeković doctrine and survives only for small, indeterminate-depth burns in unfit patients; presenting it as routine management loses the question. The second punished habit is diagnosing burn wound sepsis from fever alone — burned patients run fever from the hypermetabolic state; diagnosis needs the wound changes plus, definitively, the quantitative biopsy. The third is topical-agent mismatching: reaching for silver sulfadiazine when penetration through eschar is required (it does not — mafenide does), or prescribing silver nitrate while ignoring its hyponatraemia.
Frequently asked questions
What is the end point of tangential excision?
Viable dermis — uniform punctate bleeding and a glistening moist surface — preserving maximal dermis for take and contour; necrotic fat or fascia demands conversion to fascial excision.
How is burn wound sepsis diagnosed definitively?
By burn wound biopsy showing more than 100,000 organisms per gram of tissue with histological evidence of micro-organism invasion into adjacent viable tissue. Surface swabs colonise every burn and prove nothing.
Which topical agent penetrates eschar, and at what cost?
Mafenide acetate cream, which diffuses through eschar to reach deep bacteria; its inhibition of carbonic anhydrase produces a hyperchloraemic metabolic acidosis, and application is painful.
When is Integra chosen over conventional grafting?
In extensive burns with insufficient donor skin and in deep burns seeking better pliability: the template builds a neodermis beneath a silicone sheet over about three weeks, then a thin autograft completes closure. Cost limits routine use in Indian units.
Which nerves must escharotomy incisions avoid?
The ulnar nerve behind the medial epicondyle, the radial nerve at the distal forearm and wrist, and the common peroneal nerve at the neck of the fibula — all lie superficially in the standard midlateral escharotomy corridors; limb incisions cross joints in zigzag to avoid contracture.