TY - JOUR
AU1 - MD, Matthew B. Klein,
AU2 - PT, Merilyn L. Moore,
AU3 - OT, Beth Costa,
AU4 - MD, Loren H. Engrav,
AB - Few areas of burn care provide a greater challenge than management of the burned face. The aesthetic and functional outcomes are critical to the daily existence of the patient and are intimately related to feelings of self-esteem. Many variables contribute to the ultimate aesthetic outcome, including extent of burn injury, depth of injury, and preservation of critical areas, such as the oral commissure, mental crease, and canthi. We will review the basic principles and practices we have developed during the past 25 years at the University of Washington Burn Center at Harborview Medical Center. ACUTE MANAGEMENT It has long been our plan to excise and graft burns of the face. We recently reported our more than 20-year experience with excision and grafting of the face and believe that this method provides the best results that permit the burn patient to return to society.1,–4 We are aware of seven other articles that support the procedure and include photographic results.5,–11 We are also aware of six articles that do not support the procedure, but none of these present any photographic results.12,–17 Severe facial burns are typically accompanied by an inhalation injury that may require intubation. The endotracheal tube should be secured in a way to minimize the potential for development of a pressure sore on the lip. Similarly, if a feeding tube is placed, it should be positioned to minimize the risk of alar and columella necrosis. If there is involvement of the eye(s), it is important to perform a Wood's lamp exam to rule out corneal abrasion. If the examination results are abnormal or the patient has persistent symptoms, an ophthalmologist should be consulted. In addition, if the patient has a lagophthalmos, it is important to keep the eyes well moisturized with ophthalmic ointment to prevent exposure keratitis. Tarsorrhaphy is rarely necessary in the early burn period. On admission to the burn center, the face is débrided of blisters and loose tissue. Topical antimicrobials are then applied. The depth of the wound typically dictates the choice of topical agent. Superficial- and intermediate-depth partial-thickness wounds can safely be treated with bacitracin ointment. Deeper burns typically are treated with silver sulfadiazine to help prevent wound desiccation and provide antimicrobial protection. Silver sulfadiazine is always used on the ears to prevent chondritis.18 The face is washed twice daily with soap and water and then the topical agent is reapplied. Daily wound care is continued until day 10. At this time, the facial burns are evaluated to determine which areas will heal within 3 weeks time from the injury. A plan is then formulated for the excision and skin grafting of these areas. It is important to note that full-thickness burns with clearly no potential for healing will be scheduled for excision and grafting within the first 7 to 10 days if the patient is stable and other procedures are not more urgent. Preoperatively, patients should be blood typed and crossed, given the typical blood loss experienced during excision of the face. Positioning the patient and the endotracheal tube in the operating room requires careful consideration. All operations should be performed under general anesthesia with the patient in the reverse Trendelenburg position. The endotracheal tube should be wired to the teeth and suspended from overhead hooks. If the patient is to remain intubated for a prolonged period after the procedure, a portion of an arch bar can be wired to the teeth and the endotracheal tube attached to the arch bar to minimize pressure necrosis of the lip. We also will commonly place scleral shields to protect the cornea. Intravenous vancomycin (if the patient is not allergic) should be administered before the start of the case. Once the patient is adequately anesthetized, the face dressings are removed and the face is cleaned of any loose debris and pseudoeschar with a Norsen Debrider (Bel-Med, Langley, WA). Then, using a marking pen, mark the aesthetic units19 that are deemed unlikely to heal in the desired 3-week time period. Often a small portion of an aesthetic unit will be unburned or will have already healed before surgery. In these cases, for optimal aesthetic outcome, the areas are included in the excision. Conversely, only a small area of an aesthetic unit may be unhealed. In these instances one must consider letting the area heal and plan on reconstruction secondarily if it becomes necessary. We then excise all eschar, obtain hemostasis, and cover the face with allograft skin. The allograft skin will provide a “test” of the suitability of the excised wound bed to accept a graft and also will provide a more hemostatic wound bed at the time of autografting. Goulian knives are used to conduct the burn excision on large flat areas. In small tight areas, the excision is performed with a knife, iris scissors, or the Versajet™ Hydrosurgery System (HydroCision, Andover, MA). Wound hemostasis is achieved using epinephrine (1:10,000) soaked Telfa Pads (Kendall, Mansfield, MA). Larger vessels are treated with Bovie electrocautery. The eyelids are typically excised first. Silk traction sutures are placed through the eyelid margins to put them on adequate tension to allow facile excision. Careful attention must be paid when excising the medial canthal area because this small, tight area can be quite challenging. Sharp iris scissors, a Number 15 scalpel blade, or the Versajet™ may facilitate excision in this area. The nose usually is excised next, followed by the upper and lower lips and chin. The Goulian knife is again used for these areas. We will typically use the 0.008-inch guard for these areas. The intricacies of these areas that are critical to “normal” appearance need to be preserved if at all possible, and therefore the excision should be quite shallow, with care taken to stop the excision once bleeding tissue is encountered. Once the intricate areas of the midline of the face have been excised and hemostasis achieved, attention can be directed to the cheeks, forehead, and neck. Goulian knives (usually 0.012 to 0.014 inches) can be used for these areas. We usually do not excise the eyebrows with the hope that a portion will heal spontaneously and leave some hair in this area. The ears are another challenging area to excise. The Goulian knife is inadequate to excise the detailed three-dimensional structure of the ear. In addition, excision again needs to be conducted with great care so as to not expose cartilage unnecessarily. Our traditional practice was to allow the eschar to separate spontaneously from the wound and autograft the granulation tissue. More recently, we have begun using the VersaJet™ because it offers an easy and relatively precise way of excising eschar and is particularly useful for excision of the concave surfaces of the ears. Small areas of exposed cartilage are excised to allow for skin grafting. Once excision and hemostasis is complete, sheet allograft is placed over the wound and fixed with sutures and staples. Xeroform gauze is placed over the allograft and a pressure garment bubble is applied over the head. On postoperative day 1, the dressing is removed so that the allograft can be deblebbed. The allograft remains in place for 5 to 7 days. We return the patient to the operating room, and under general anesthesia, the allograft is carefully inspected. Adherent allograft signifies an adequately excised wound bed, one that is ready to accept an autograft. Areas where the allograft is not adhering will likely require additional excision and reapplication of allograft. Once the decision to proceed with autografting is made, the patient will be positioned based on the planned area of autograft harvest. Our preferred source for autograft skin is the scalp because it will provide the best color match. Scalp harvest is best conducted with the patient's head positioned in a Mayfield neurosurgical headrest. The headrest should be set so that the U-shaped piece projects directly upward and a few folded towels are placed under the neck. Using a template of the recipient site, a pattern for harvesting is traced on the scalp. The scalp skin is then tumesced using saline containing epinephrine (1:500,000) to facilitate harvest. On occasion adequate scalp skin is unavailable (ie, if the area is burned) or not practical given the size of the facial graft needed and the desire for uniformity of color and, therefore, a secondary skin source is necessary. Before the start of grafting, if there is a plan to apply elastomer under pressure garments, the therapists will make a negative impression of the face using Jeltrate (Dentsply International, Milford, DE) with plaster reinforcement. Occasionally foam alone is sufficient. Plaster strips alone can be used when only a portion of the face is involved. The allograft is then removed and epinephrine-soaked Telfa pads are applied to the wound bed to achieve hemostasis. More recently, we have been using Tisseel fibrin sealant (Baxter, Deerfield, IL) to both assist in hemostasis and in graft adherence. While hemostasis is being obtained, autograft is harvested, usually at a 0.018- to 0.021-inch thickness in adults and 0.008- to 0.012-inch thickness in children. Skin grafts are stitched in place using fine plain gut suture. It is important to make sure the grafts are spread tautly to optimize graft appearance and prevent wrinkling or shriveling. Overlapping of grafts seems to improve the appearance of graft junctures. Eyelid grafting is conducted using full-thickness grafts whenever possible.20 The grafts should be applied with the eyelids pulled by traction sutures and the eyelid grafts should be fixed with bolsters. If all four lids need to be grafted, the lower lids may be stretched and positioned under the upper lids. The face is then dressed with Xeroform gauze and the scalp donor, if used, is dressed with Bioclusive (Johnson and Johnson Medical, Arlington, TX). An elastomer mold is then placed over the face and a Jobstskin interim featureless facemask (Bielsdorf-Jobst, Inc., Rutherford College, NC) is carefully placed over the entire head. The dressing is removed on postoperative day one to allow for graft inspection and deblebbing if necessary. If any significant hematoma is present, the patient should be returned to the operating room for evacuation. We do not routinely paralyze patients after face grafting. If the patient was intubated before surgery, we will usually keep him or her intubated for 3 to 5 days after the procedure. However, if the patient was not intubated, we will extubate the patient postoperatively, but he or she will receive enteral nutrition via feeding tube for 3 to 5 days and encouraged to refrain from talking. Patients are instructed to wear custom pressure masks for several months after grafting. Facemasks of various materials can be fabricated, the most common of which are silicon elastomer and plastic. If the plastic mask is used, there is a need for frequent monitoring because there is increased risk for pressure sores over bony prominences if the mask does not fit well. Regardless of the type of mask used, monthly modification is necessary to maintain sufficient pressure over the scar and to counteract shrinkage. In addition, the mask should be removed for hygiene and several brief periods of exercise daily. Oral commissure splints and nasal splints also can be used to minimize microstomia as well as collapse of the nasal alae. Silicone sheeting also is used occasionally in an effort to minimize hypertrophic scarring.21 SECONDARY RECONSTRUCTION Feldman22 and Achauer23 have described the general principles of reconstruction after face burns. Secondary reconstruction of the burned face is typically conducted approximately 12 months after initial skin grafting. Graft maturity and maximization of benefits from aggressive physical therapy are crucial prerequisites for performing secondary reconstruction. It is important to consider that after maturation, many scars may actually be more acceptable than the results of secondary reconstruction. The most obvious exception to delayed secondary treatment is severe, cicatricial ectropion that places the underlying globe at risk for ulceration. We will briefly review some of the most common issues involved in secondary reconstruction. Before embarking on a reconstructive endeavor, it is crucial to formulate a precise, comprehensive plan with the patient and his or her support system. Nurses, therapists, and psychologists working with the patient also must be involved in the planning phases. It is critically important that the patient has realistic expectations as to the outcome of procedures and equally important that the surgeon have a clear understanding of the patient's goals. If possible, operations should be coordinated so as to minimize overall number of procedures and minimize the overall time of incapacity. Hypertrophic scar is uncommon in areas that have been excised and grafted without complication. However, small areas may form hypertrophic scars and may be amenable to direct excision and closure. If there are larger areas of hypertrophic scarring, excision of the area, and possibly the entire aesthetic unit, with regrafting may be necessary. Cicatricial ectropion of the upper and lower eyelids is one of the most common problems after facial burns. As mentioned previously, the correction of ectropion need not be delayed until full scar maturation because the risks of corneal ulceration are so high. Typically, ectropion release is conducted by scar release and regrafting of the affected area (upper and/or lower eyelid). If grafting of the eyelids was required, there is a high likelihood that medial canthal webs will develop. A mild-to-moderate deformity with tissue between the web and the canthus can usually be corrected with a double opposing Z-plasty or other small flap rearrangement. If the web is large, the only option is to incise and remove the web and skin graft the resultant defect.3,24 Eyebrow alopecia is another common problem after deep facial burns. The absence of eyebrows can be quite conspicuous. Tattooing or use of eyebrow pencil are two viable nonoperative options. However, if the patient desires an attempt at providing the area with native hair, then strip grafts from the temporal scalp can be used as described by Brent and others.3,24,25 Defects of the nose and mouth can occur quite commonly as well. Alar retraction and nostril flaring are common sequelae of deep burns to the nose. Releasing and grafting the alar groove is usually the best management. In cases of alar notching caused by focal loss of nasal tissue, incision and release of the alar groove with composite cartilage-skin grafting can be conducted to replace missing tissue. In the rare cases of severe nasal deformity, nasal reconstruction with regional (forehead) or distant (free radial forearm or Tagliacozzi) flaps may be necessary. Reconstruction of the mouth provides many challenges. There are both significant functional and aesthetic considerations. Contracture of the mouth with resultant microstomia can significantly impair oral opening and, thus, the ability to eat. The commissuroplasty procedure described by Converse can be helpful in reestablishing the length of the mouth. A triangle of skin graft at each commissure is removed, the oral mucosa is then advanced outward and sutured in place.3,24,26 The intricate structure and subtle lines of the upper lip can be easily destroyed after burn injury. Restoration of appropriate length of the upper lip by scar release and skin grafting is a common procedure in secondary reconstruction. Defects of the lower lip resulting in lower lip contracture can similarly be treated by scar release skin grafting. It is important to achieve a full release of the lower lip (so that all teeth are covered) before skin grafting. Recreation of the mental crease is another critical component to reconstruction. On occasion, a chin implant is helpful in reestablishing chin projection.3,24 FUTURE DIRECTIONS The development of skin substitutes during the past two decades has been heralded as a major advance in burn care. However, despite rigorous research efforts, there remains no “off-the-shelf” substitute for autograft skin. There have been reports of the use of products such as Integra™ (Integra Life Sciences, Plainsboro, NJ) and TransCyte (Smith and Nephew, London, United Kingdom) for facial burns, yet no articles have been published detailing a large-scale experience. CONCLUSIONS Management of facial burns can be a demanding and often frustrating endeavor. We have provided a set of principles for approaching and managing burns of the face. On the basis of our experiences, excision and skin grafting provide the best functional and aesthetic outcome. Reconstructive procedures are best conducted once skin grafts mature and a reasonable plan can be formulated with the patient and burn team staff. Despite our successes, our practice continues to evolve as we gain more experience and evaluate the potential of newer technologies that could improve our outcomes. ACKNOWLEDGMENTS We thank the countless burn team members who struggled with these problems for the past 20+ years. We also are grateful to the burn survivors who struggled with these problems and who permitted their photographs to be used in this effort to improve burn outcomes. REFERENCES 1. Cole JK, Engrav LH, Heimbach DMet al.   Early excision and grafting of face and neck burns in patients over 20 years.. Plast Reconstr Surg  2002; 109: 1266– 73. Google Scholar CrossRef Search ADS PubMed  2. Engrav LH Primary and secondary reconstruction of the burned face. Grotting J Reoperative aesthetic and reconstructive surgery.  St. Louis Quality Medical Publishing; 1995. 3. Engrav LH, Donelan MB Face burns: acute care and reconstruction.. Op Tech Plastic Reconstr Surg  1997; 4: 53– 85. Google Scholar CrossRef Search ADS   4. Engrav LH, Heimbach DM, Walkinshaw MD, Marvin JA Excision of burns of the face.. Plast Reconstr Surg  1986; 77: 744– 51. Google Scholar CrossRef Search ADS PubMed  5. Bloem JJ, Hermans RP The deeper burn of the face and surrounding areas.. Burns  1976; 2: 124– 7. 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TI - Primer on the Management of Face Burns at the University of Washington
JF - Journal of Burn Care & Research
DO - 10.1097/01.BCR.0000150213.07348.06
DA - 2005-01-01
UR - https://www.deepdyve.com/lp/oxford-university-press/primer-on-the-management-of-face-burns-at-the-university-of-washington-AD9Nr815gU
SP - 2
EP - 6
VL - 26
IS - 1
DP - DeepDyve
ER -