Acute management of facial burns

A B C

D E F

Fig. 4. Mixed deep partial thickness / Full thickness facial burn.

A On admission;

B Inital application of allograft;

C5 days post injury it is apparent that healing will take > 3 weeks. Areas for excision marked;

DFollowing debridement and split thickness skin grafting in cosmetic units. Scalp donor site;

E Outcome at 3 months;

FOutcome at 2 years

Adjuvant care includes post pyloric enteral nutrition using a naso-jejunal tube, which is continued until all grafts have taken and are stable, usually by day 7 postgrafting.

Continued postoperative intubation and ventilation in non-ventilated patients can be considered for 48h to preserve integrity of the grafted areas [33].

Wound closure

Depending on the size and depth of the injury as described above a single or staged approach is taken to wound closure. Following excision and appropriate hemostasis the wound is covered with either autograft or cadaver allograft. The grafts are tailored to match aesthetic units, with graft seams placed in the boundaries of units. Grafts are secured with staples or absorbable sutures.

Following wound excision cadaver allograft can be used as a good test of wound bed viability as they will vascularise. Xenografts and Biobrane can be used in a similar fashion for temporary wound closure but they do not revascularise and do not test wound viability.

Following excision and application of cadaveric allograft, further surgery is undertaken 4 to 7 days

later for definitive wound closure. If the allograft is adherent and re-vascularized, then the wound is ready for autografting. If the allografts are non-ad- herent they are removed and the underlying wound re-excised and re-allografted. This process is repeated until the allograft is adherent. If donor sites are limited in a major burn injury, repeated application of allograft may be require until adequate suitable donor sites become available. An alternative approach is to use a two-stage dermal regeneration template (Integra ) to close the wound and wait for donor site availability for second stage grafting

Split-thickness autografts are preferably harvested from the scalp to optimize texture and colour match with facial skin. In larger burn, if the scalp is burnt and if the entire face must be grafted, other donor sites must be considered. In these circumstances larger donor sites obtained from the same area should be used to ensure similar texture and colour of the grafted skin. Powered dermatomes set at 10–12 /100ths inch provide the best quality skin and the use of a 4 inch dermatome in a child and a 6 inch dermatome in an adult will ensure grafts of adequate width to resurface aesthetic units.

Biosynthetic skin substitutes or dermal regeneration templates have been popularized in recent years in the management of full thickness facial burns and have become the standard of care for these injuries in some centres particularly for panfacial burn injury [34]. One-stage dermal regeneration templates (Matriderm /Integra ) can be considered for small or isolated full thickness facial burns. In larger burns associated with pan-facial injury a two-stage technique has benefits as it closes the burn wound until precious donor sites become available. The use of dermal templates may also have benefits in children by limiting skin graft donor site morbidity by taking thinner grafts, which are usually harvested at 6–8/100ths inch.

Special areas and adjacent of the face

Eyelids

Burns to the eyelids are very common in patients with facial burn injury. Eyelid injury can signify or lead to underlying ocular damage and subsequent

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blindness. All patients with periorbital burns should undergo ocular exam on admission using fluorescein and Wood’s lamp to to show up any epithelial conjunctival loss. Early involvement of patients with corneal injury is essential. The presence of uninjured skin in the crow’s feet is a reliable clinical sign indicating absence of corneal injury [35]. Initial management includes aggressive lubrication and topical antimicrobials to prevent corneal exposure and desiccation. Early excision and skin grafting with either thick split thickness or full thickness skin grafts for full thickness eyelid burns reduces exposure keratitis, conjunctivitis, and corneal ulceration and is best undertaken within 7 days [36]. In patients with severe large total body surface areas burns with limited donor sites temporary tarsorrhaphy may be required.. Temporary tarsorrhaphy is recommended to prevent ectropion and corneal exposure although traditional tarsorrhaphy techniques traumatise the tarsal plate, cut out after a time and can even traumatize the cornea.

Unfortunately despite early excision and grafting scar contracture during the acute phase can lead to ectropion and corneal ulceration. These patients will often require release and further grafting during their acute stay.

Reversible semi-permanent tarsorrhaphy techniques have been described in patients who develop conjunctivitis which can be used both laterally and medially to protect the conjunctiva [37]. The adhesion of the lower to the upper eyelid may also be helpful in counteracting scar contracture.

Nose and ears

The nose and ears are facial appendages that consist of a cartilaginous / bony framework with closely applied overlying skin. This means that in deeper burns the underlying skeleton is exposed and or involved which can lead to vital tissue loss and structural support leading to subsequent deformity. These areas are subsequently a significant reconstructive challenge.

Ear management in the acute phase requires preservation of the cartilaginous structures by the judicious use of topical antimicrobials and avoidance of desiccation [38]. This has reduced the incidence of suppurative chondritis and its devastating

consequences. Some authors advocate the use of early debridement and flap cover to preserve ear cartilage and undertake this in patients with major injuries [39], although in practice most surgeons treat these injuries expectantly with grafting as when donor sites become available.

Nasal burn injury presents simpler problem, as therapeutic options are limited. Excision and resurfacing is usually undertaken at the same time as the rest of the face but it is not uncommon for the nasal cartilaginous skeleton to be involved and exposed leading to total or subtotal loss of the nose.

Lips

Injuries to the lips are treated according to the different structures involved. Mucosal injury is usually managed conservatively and will heal spontaneous. Pain and contact bleeding are an issue and oral nutrition may not be tolerated necessitating tube feeding. The cutaneous portions of the lips are treated in conjunction with the rest of the face and are debrided and grafted at the same time for the same indications. Special attention must be paid in wound care to the hair bearing lip and beard area in males. Regular shaving to control hair growth and the build up of necrotic debris and exudate is important in the prevention of chronic folliculitis and infection.

Scalp

Although the scalp is a distinct anatomical entity it is useful to consider management of burn injuries to this area at the same time as the face as the two commonly coexist. In general management of scalp burns is relatively conservative with meticulous wound care, topical antimicrobials and an expectant policy. This is because the scalp is a highly specialized area of skin, it has a very high density of hair follicles many of which are sub dermal and healing potential is much greater even in those injuries that clinically appear to be full thickness. In injuries that have the potential to heal, meticulous wound care including regular shaving of the scalp must be undertaken to prevent hair growth, clogging up with necrotic tissue and debris which leads to infection and chronic folliculitis. Not only is this painful and distressing for the patient it can lead to unnecessary

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