TY - JOUR
AU - Mayer, Horacio, F
AB - Abstract Management of third-degree facial burns remains one of the most difficult challenges in burn care. Patients with deep facial burns usually require gradual escharectomy, tangential excision of the wound, and resurfacing with full-thickness skin grafts or dermal substitutes associated with split-thickness skin grafts to provide better and superior cosmetic results. Immobilization of skin grafts and dermal substitutes by reducing shearing forces and hematoma formation underneath is paramount to improve success rates. Due to the irregular shape of the face, the proper immobilization of grafts with traditional methods is often difficult, especially over concave portions of the face. Herein, we report the original use of a custom three-dimensional printing facemask for securing dermal substitutes and skin grafts to difficult sites on the face. Deep facial burns are notoriously difficult to repair, and their management poses a series of problems to the surgeon.1 Full-thickness skin grafts (FTSG) or dermal substitutes associated with split-thickness skin grafts (STSG) are preferred to treat third-degree facial burns since they provide superior cosmetic outcomes.2–4 Immobilization of FTSG and dermal substitutes by reducing shearing forces and hematoma formation underneath is paramount to improve success rates. Tie-over bolster dressings, quilting sutures and negative wound pressure therapy (NWPT) are typically employed methods for securing grafts, but they might be problematic when used in extended facial areas or over the whole face.5–7 Also, due to the irregular shape of the face, the proper immobilization of grafts is often difficult, especially over concave portions of the face. Because of this, a personalized facial mask is an attractive method for securing facial skin grafts or dermal substitutes. With the help of specialized software programs and the advancement of three-dimensional (3D) printing,8–10 a personalized facemask can be created to facilitate the fitting of the facial contour and properly securing the facial skin graft or dermal substitute. Transparent polycarbonate facemasks have been used for almost 40 years for the prevention and treatment of postburn facial hypertrophic scars. Lately, very few reports on the use of 3D custom facemasks for such purpose are available.11–14 In addition, the use of any mask for securing skin grafts or dermal substitutes for the treatment of deep facial burns has not yet been reported in the medical literature. Herein, we report the original use of a personalized 3D printing facemask for securing dermal substitutes and skin grafts to difficult portions of the face. Case Report A 38-year-old patient was admitted to our burn unit and was the survivor of a car explosion. The patient had third-degree flame burns over greater than 40% of the TBSA, compromising the hands, forearms, and legs and exhibiting extensive facial damage including forehead, eyelids, nasal region, and both cheeks (Figure 1A). Figure 1. Open in new tabDownload slide A. Frontal view 48 hours after facial burn injury; B. frontal view at day 8 after enzymatic debridement with collagenase/chloramphenicol ointment; and C. at day 15, the granulation tissue at the wound bed is already suitable for grafting. Figure 1. Open in new tabDownload slide A. Frontal view 48 hours after facial burn injury; B. frontal view at day 8 after enzymatic debridement with collagenase/chloramphenicol ointment; and C. at day 15, the granulation tissue at the wound bed is already suitable for grafting. The initial treatment plan was based on gradual escharectomy followed by application of enzymatic debridement with collagenase/chloramphenicol ointment (Iruxol™, Abbott Laboratories, Rio de Janeiro, Brazil) and it was conducted during the first 2 weeks (Figure 1B and C). At this stage, the patient’s facial features were scanned with a portable 3D scanner and a simulation software program, which is usually used in cosmetic surgery (Crisalix™ Virtual Aesthetics, Crisalix, Lausane, Switzerland) (Figure 2A). The image was then edited to create a personalized mask, and it was then converted to printable files. A white polylactic acid (PLA) facemask was directly printed out using a 3D printer (Ultimaker 3 Extended™, Ultimaker, Geldermalsen, The Netherlands) (Figure 2B). The facemask design included lateral openings on both sides to fit the mask to the patient´s face with elastic straps. Figure 2. Open in new tabDownload slide A. The patient’s facial features are scanned with a portable 3D scanner and a simulation software program. B. The image obtained is then edited to create a personalized mask that is directly printed out using a 3D printer. Figure 2. Open in new tabDownload slide A. The patient’s facial features are scanned with a portable 3D scanner and a simulation software program. B. The image obtained is then edited to create a personalized mask that is directly printed out using a 3D printer. At day 15, once the granulation tissue at the wound bed was suitable for grafting, the patient was taken to the operating room. In our practice, in order to increase the success rates and due to financial constraints, we prefer to wait till total granulation of the wound before grafting. Both eyelids were immobilized by a bilateral tarsorraphy and grafted with FTSG obtained from the retroauricular area. The forehead, full nose, and both cheeks were covered using a bilayer dermal matrix (Integra™, Integra LifeSciences, Plainsboro, NJ) (Figure 3A). The full facial area, including the eyelids and excluding the mouth and nostrils, was covered with dressings containing nanocrystalline silver (Acticoat ™, Smith & Nephew, London, UK) to provide a humid and isolated environment and prevent infections. Then, the previously sterilized 3D facemask was fit to the patient with elastic straps and kept in place for 7 days, not being removed to ensure perfect integration (Figure 3B). Figure 3. Open in new tabDownload slide A. Immediate postoperative view with both eyelids grafted with full-thickness skin grafts obtained from the retroauricular area and forehead, full nose and both cheeks covered using a bilayer dermal matrix. B. The full facial area, excluding the mouth and nostrils, was covered with dressings containing nanocrystalline silver and the previously sterilized 3D facemask was fit to the patient with elastic straps. C. Postoperative view at day 21 when the silicone layer is removed showing full integration of the dermal substitute. D. Immediately unmeshed partial-thickness skin grafts are placed on the integrated dermal substitute. E. Postoperative view 7 days later showing total integration and vitality of the autologous skin grafts. F. Late postoperative view at 4 months showing acceptable skin color match. Figure 3. Open in new tabDownload slide A. Immediate postoperative view with both eyelids grafted with full-thickness skin grafts obtained from the retroauricular area and forehead, full nose and both cheeks covered using a bilayer dermal matrix. B. The full facial area, excluding the mouth and nostrils, was covered with dressings containing nanocrystalline silver and the previously sterilized 3D facemask was fit to the patient with elastic straps. C. Postoperative view at day 21 when the silicone layer is removed showing full integration of the dermal substitute. D. Immediately unmeshed partial-thickness skin grafts are placed on the integrated dermal substitute. E. Postoperative view 7 days later showing total integration and vitality of the autologous skin grafts. F. Late postoperative view at 4 months showing acceptable skin color match. After 3 weeks, the silicone layer was removed, excessive granulation tissue from small not grafted areas at both sideburns was debrided, and unmeshed 2-mm partial-thickness skin grafts (PTSG) were placed on the perfectly integrated dermal substitute (Figure 3C and D). Again, nanocrystalline silver dressings and the personalized mask were applied to immobilize the PTSG till postoperative day 7 when the total integration and vitality of the autologous skin grafts were verified (Figure 3E). Postoperative care included facial wound care with Vitamin A cream on daily basis and cleansing of the mask with a 70% alcohol solution. As this was a partial face mask, it was not necessary to remove it for meals or oral hygiene. On postoperative day 28, pressotherapy was initialized with the same customized PLA facemask. The interface pressure between the facemask and the patient’s face was optimized through the addition of an internal silicone lining. The patient was instructed to wear the facemask for at least 20 hours per day. The treatment was well tolerated and no complications were found. At the 6-month follow-up, optimal healing of the face with acceptable skin color match was obtained and, more importantly, functional or cosmetic sequelae were avoided (Figure 3F). DISCUSSION Management of third-degree facial burns remains one of the most difficult challenges in burn care.1 Patients with deep facial burns usually require gradual escharectomy, tangential excision of the wound and resurfacing with FTSG or dermal substitutes associated with STSG to provide superior cosmetic results.2–4 The anatomy of the face complicates this scenario even more as it is an irregular surface with many concave areas that make the perfect adaptation of the graft difficult. The presence of the palpebral fissures, nostrils, and mouth also makes the procedure problematic. Different methods of securing skin grafts or dermal substitutes have been described in the medical literature,5–7 and the tie-over bolster dressing is the most frequently used. No differences have been found when comparing tie-over bolster dressing to the use of quilting sutures, which is also a widely used method.7 More recently, the NWPT has been proposed as a successful method for securing skin grafts, especially in joint areas.5,6 Although all of these methods have proven to be reliable in securing and ensuring successful skin grafts or dermal substitutes, their use is still problematic when managing extensive facial wounds requiring resurfacing. In these cases, the use of a personalized facemask solves many problems since it perfectly adapts to the face topography and can be used for securing the skin grafts or dermal substitutes. It is also beneficial for the prevention and treatment of facial hypertrophic scars. A transparent polycarbonate facemask has been used to successfully prevent and treat postburn facial hypertrophic scars for decades. However, the conventional method of manufacturing a personalized facemask for this purpose requires the creation of a plaster mold, after which a polycarbonate sheet is molded over the plaster mold. It is important to note that this is only possible when the face wounds have completely healed. Modern technologies like stereophotogrammetric cameras9 and laser scanning10 allow for noncontact scanning of the face, even when the facial wounds have not been healed, obtaining 3D images that can be converted to printable files. However, the main problem with these technologies is its prohibitive cost. In order to overcome this obstacle, we decided to use a popular simulation software program for cosmetic surgery along with a portable scanner to obtain 3D images of our patient. The images were then transferred to a 3D printer. 3D printers have become very affordable, and the PLA filament used for printing is also inexpensive. The total cost of production of this face mask was just 100 USD. The PLA facemask created in this way perfectly adapts to the patient´s face and provides ideal compression both for securing grafts and for preventing hypertrophic scarring. Additionally, the PLA facemask can be easily sterilized using ethylen oxide or plasma methods. The treatment was well tolerated by our patient. Furthermore, a very good evolution was found and no complications related to the use of the facemask were observed. The procedure presented here using a personalized 3D-printed facemask can be effective in both securing dermal substitutes and skin grafts and preventing hypertrophic scars after burns. Additional prospective clinic studies including a large cohort of patients are warranted to confirm our promising initial result. Funding: This study was not funded. Conflicts of interests: The authors declare no conflict of interests. REFERENCES 1. Leon-Villapalos J , Jeschke MG , Herndon DN . Topical management of facial burns . Burns 2008 ; 34 : 903 – 11 . 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Eur J Plast Surg 2018 ; 41 : 571 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 10. Kovacs L , Zimmermann A , Brockmann G et al. Accuracy and precision of the three-dimensional assessment of the facial surface using a 3-D laser scanner . IEEE Trans Med Imaging 2006 ; 25 : 742 – 54 . Google Scholar Crossref Search ADS PubMed WorldCat 11. Wei Y , Li-Tsang CWP , Liu J , Xie L , Yue S . 3D-printed transparent facemasks in the treatment of facial hypertrophic scars of young children with burns . Burns 2017 ; 43 : e19 – 26 . Google Scholar Crossref Search ADS PubMed WorldCat 12. Wei Y , Wang Y , Zhang M et al. The application of 3D-printed transparent facemask for facial scar management and its biomechanical rationale . Burns 2018 ; 44 : 453 – 61 . Google Scholar Crossref Search ADS PubMed WorldCat 13. Seol YJ , Lee H , Copus JS et al. 3D bioprinted biomask for facial skin reconstruction . Bioprinting 2018 ; 10 ; e00028 . doi: https://doi.org/10.1016/j.bprint.2018.e00028 . Google Scholar Crossref Search ADS PubMed WorldCat 14. Kant SB , van den Kerckhove E , Colla C et al. A new treatment for reliable functional and esthetic outcome after local facial flap reconstruction: a transparent polycarbonate facial mask with silicone sheeting . Eur J Plast Surg 2018 ; 41 : 69 – 80 . Google Scholar Crossref Search ADS PubMed WorldCat © American Burn Association 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - A New Method for Securing Dermal Substitutes and Skin Grafts to Difficult Portions of the Face Using a Custom 3D-Printed Facemask
JF - Journal of Burn Care & Research
DO - 10.1093/jbcr/irz128
DA - 2019-10-16
UR - https://www.deepdyve.com/lp/oxford-university-press/a-new-method-for-securing-dermal-substitutes-and-skin-grafts-to-cFqdiQLjzy
SP - 1015
VL - 40
IS - 6
DP - DeepDyve
ER -