Initial Management of Facial Burns

Initial assessment of all facial burns should start by ruling out inhalation injury and need for intubation.

A history of burns occurring in an enclosed space is a risk factor for inhalation injury. As such, inhalation injury must be ruled out when signs such as expectoration of soot, wheezing, and singed nasal vibrissae are present. If intubation is necessary, care should be taken to secure the endotracheal tube in such a fashion that prevents pressure necrosis. Insertion of a feeding tube should be performed in all patients being intubated and those with burns on greater than 20% total body surface area. This should be secured in a way as to prevent pressure necrosis of the columella. The authors prefer to place a Dobhoff tube in a postpyloric position, when possible, and to secure this with a nasal bridle. Any patient with periorbital burns must have a corneal examination by means of a Wood’s lamp. If injury to the cornea is suspected, an ophthalmology consult for further workup and management is ascertained. Aggressive lubrication of the eyes is considered routine burn care and should be started immediately as part of the initial management of any facial burn.

Once initial assessment of the facial burn has been performed and any airway issues have been addressed, burn wounds of the head and neck should be cleansed with an antibacterial soap. Removal of debris and debridement of any blisters in which the epithelial covers have been disrupted is essential to proper cleansing. Hair-bearing areas of the scalp and face involved in the burn injury should be shaved frequently with electric clippers to keep short. Topical antimicrobials should be placed over the clean burn wound every 6 hours to keep it moist.

Topical Antimicrobials

Following cleansing of the wound, topical antimicrobials should be used as first-line care in burn wound management for prevention and control of wound infections. In choosing a topical antimicrobial agent, the decision should be for an agent that is easy to apply and remove with gentle cleansing, lacks tissue toxicity, is broad spectrum, and has adequate eschar penetration. Creams and ointments are generally preferred to solutions in this area of the body because of the contours of the face and ease of its application.

Silver sulfadiazine cream 1% is effective against gram-positive and gram-negative bacteria, and fungus. It is applied twice daily. The use of silver sulfadiazine cream, however, is limited in facial burns, especially in children younger than 2 years of age, secondary to its potential damaging effect on the eyes and toxicity if ingested.

Mafenide acetate is also highly effective against both gram-positive and gram-negative bacteria. It also has good eschar penetrance, which makes it a good topical antimicrobial for exposed cartilage in full-thickness burns to the ears and nose. Unfortunately, inflammation and pain with application make it a less favorable option for wound care to the rest of the face.

Bacitracin ointment, effective against gram-positive bacteria, is the authors’ topical antimicrobial of choice for burns to the face and scalp and is applied every 6 hours. Bacitracin is less irritating to the eyes, has minimal to no systemic effects, and is easy to remove between applications. Placement of a nonstick dressing, such as a petroleum jelly–impregnated gauze, over the bacitracin between applications is highly effective at providing a moist healing environment for both partial-thickness and full-thickness burns. Mupirocin is useful in patients known to be MRSA colonized.

Management of Partial-Thickness Burns of the Head and Neck

Determining the depth of injury can be very difficult immediately following a burn to the head and neck. Because of the rich vascularity and high density of skin appendages, the face and scalp generally heal quickly with decreased risk of infection and scarring. Burn wounds to the head and neck should be managed expectantly unless they are clearly full-thickness in nature, at which point, early tangential excision and grafting should proceed once the patient is medically able to undergo such an operation. Partial-thickness burns should be reassessed for healing potential around 10 days postburn. Partial-thickness burns usually show significant signs of healing, if not healed, by 14 days following initial injury. This helps to differentiate these wounds from full-thickness injury.

Nonoperative Management of Partial-Thickness Burns

Treatment of partial-thickness burns was historically mostly nonoperative in nature. Frequent dressing changes and daily washing allowed for superficial debridement of the wounds and provided a moist environment for healing. Such nonoperative treatments are still routinely used for partial-thickness burns to the face and scalp with the various topical treatments (see previous discussion). Another approach to the management of partial-thickness burns is by mechanical debridement and the application of skin substitutes.

Skin Substitutes in the Management of Partial-Thickness Burns

Debridement of partial-thickness wounds by tangential excision can result is loss of undamaged skin appendages critical to re-epithelialization. Dermabrasion, using traditional metal burrs on a rotating electric motor or a manual simpler electrocautery scratch pad, is a reliable tool for in the treatment of partial-thickness burns. The use of this technique allows for controlled removal of damaged cells, while protecting underlying intact structures necessary for re-epithelialization. This is especially useful in head and neck reconstruction given the contours of the face, which make tangential excision more difficult than in other areas of the body. Another useful tool for debridement of partial-thickness burns of the head and neck is the water-jet system, which allows for precise and rapid debridement with simultaneous removal of debris. Once this damaged tissue has been removed, a more reliable assessment of burn depth and healing potential can be ascertained.

Following debridement, skin substitutes may be used because their ability to adhere and integrate to the contours of the face decrease the number of dressing changes required during the course of a hospitalization. This, in turn, decreases patient pain and discomfort. In addition, skin substitutes promote rapid re-epithelialization and decrease the risk of infection when compared with conventional topical treatments and dressing changes, and reduce evaporative losses of water, protein, and heat. Skin substitutes that have been well studied for their advantages in healing of partial-thickness facial burns include porcine xenograft, human allograft, human fibroblast-derived temporary skin substitute (TransCyte, Advanced Tissue Sciences, La Jolla, CA, USA), other collagen constructs, and amniotic membranes. Allogenic skin has also been shown to not only increase the rate of re-epithelialization but also decreases the incidence of hypertrophic scarring, thereby improving cosmetic outcome. Amniotic membrane adheres and conforms well to the contours of the face, and has low antigenicity and good antimicrobial potential. It, too, has been shown to increase rate of re-epithelialization.

Management of Full-Thickness Burns of the Head and Neck

Historically, full-thickness burns of the head and neck region were treated with dressing changes until spontaneous separation of the eschar from underlying granulation tissue occurred. At this time, autografting on top of granulation tissue could be pursued. This method often led to hypertrophic scarring because burns that heal after 21 days have greater than double the risk of hypertrophic scarring compared with those that heal between 14 and 21 days. The concept of early tangential excision and grafting was introduced by Janzekovic in 1970 and has become the treatment of choice in head and neck full-thickness burn injury as a way to minimize hypertrophic scarring and improve cosmetic outcomes. Early excision and sheet grafting yields results that permit the burn survivors to return to society and minimize the time off work or out of school.

Because it can be difficult on initial presentation to differentiate between partial-thickness and full-thickness burns of the head and neck, it is recommended to re-evaluate the wounds after 10 days. Most partial-thickness burns show signs of spontaneous healing by this time. If the wound is not likely to heal by 21 days postburn, surgical excision and skin grafting is recommended. Burns that are clearly full-thickness are excised and skin grafted as soon as the patient’s medical status permits. The goal is to have the burn wound treated and skin grafted within 14 days of the burn injury.

In panfacial burns, the eyelids should be excised first, followed by the nose, upper and lower lip, chin, cheeks, and then forehead. The eyebrows should be spared if spontaneous healing will preserve some hair in this area. In facial burn reconstruction, it is important to adhere to the aesthetic unit principle in which small, unburned areas of an aesthetic unit to be excised should be included at the time of resection and grafted as a whole.

Standard tools for tangential excision include the Goulian knife, the dermabrader, scratch pad, curette, and scalpel. Once the wounds have been excised and hemostasis achieved, many investigators advocate a 2-stage approach to reconstruction with allograft placement before skin grafting. Allograft is left in place anywhere from 48 hours to 1 week before skin grafting. The allograft acts as a test to determine if the wound bed is ready for autografting from a microbiology and a vascular consideration. If the allograft is adherent to the underlying wound, the burn has been adequately excised. If it is not, then that area of burn will require further excision or infection treatment before autografting.

The Integra Dermal Regenerative Template (Integra LifeSciences Corporation, Plainsboro, NJ, USA) is a bilaminar structure consisting of a layer of cross-linked bovine collagen and chondroitin-6-sulfate. An outer silastic layer is also used in the first step toward reconstruction of burns of the head and neck. It is meshed and fixed to the wound bed after tangential excision is performed. Once it becomes vascularized, Integra forms a neodermis that is capable of accepting a much thinner autograft. This process takes approximately 2 weeks before autografting is possible. Results from the use of Integra and split-thickness skin grafts, have shown to produce acceptable color match and texture with graft-graft junctures being less evident. Newer formulations of Integra are thinner (without the silastic outer layer) and potentially allow for single-staged reconstruction of a more full-thickness–like graft. The use of Integra and delayed autografting on full-thickness eyelid burns, however, leads to ectropion and is, therefore, not recommended. Full-thickness eyelid burns should be grafted immediately following tangential excision.

Thicker split-thickness skin grafts are generally preferred for the reconstruction of the head and neck, except when using Integra. Skin grafts are harvested at a thickness of 0.018 to 0.025 of an inch in adults and 0.008 to 0.012 of an inch in children. The thicker skin graft decreases the amount of secondary contracture that occurs during healing. The scalp is the donor site of choice when available, followed by the upper back and chest, and, less frequently, the abdomen and thighs. In the case of large total body surface area burns, grafts for the face are obtained wherever adequate skin is available and set aside before harvesting skin graft of the rest of the body.

Treatment of Burns to the Eyelids and Ears

Delayed treatment of full-thickness burns of the eyelids can lead to exposure keratitis and corneal ulceration because the wound contracts and ectropion ensues. Early eyelid release and skin grafting has been shown to reduce the incidence of these complications. Split-thickness skin grafts used for upper eyelid reconstruction fold and drape well compared with thicker grafts. However, full-thickness skin grafts may lead to decreased rates of retraction and ectropion. Full-thickness skin grafts are almost always chosen for lower eyelid reconstruction, again, to decrease the rate of secondary contraction and ectropion of the lower eyelid. Temporary tarsorrhaphies may be necessary to protect the cornea while the grafts mature.

Partial-thickness and full-thickness burns to ears are treated acutely with topical antimicrobials. Mafenide acetate, when applied twice daily, is the treatment of choice for burns to the ears given its superior eschar penetration and prevention of chondritis. For patients who cannot tolerate the painful side effects of this treatment, betadine ointment or silver sulfadiazine can also be applied to the burn eschar. Full-thickness burns to the ears should be managed expectantly, allowing the eschar to spontaneously separate, at which point autografting can be performed over granulation tissue, or local flaps, if available, can be used for coverage of exposed cartilage as needed to maintain 3-dimensional ear contours.

Postoperative Management

Once open burn wounds have healed, there are several therapies in which to minimize scars and assist in their maturation. Topical silicone gel is a mainstay in therapy to encourage scar maturation. Compression therapy is known to minimize hypertrophy of scars. Computer-molded compression masks allow direct pressure to the point of blanching of the scars. Splints are also used to maintain optimal length of scars and prevention of postoperative contractures. Often the neck is splinted in the acute phase in the neutral position and serially with increasing extension to improve range of motion and minimize contracture. Physical therapy and range of motion is rarely started in the emergent phase but is initiated in the acute phase. Massage and stretching are initiated at this time as well. Massage can be used to encourage orientation of the collagen fibers.

Initial Management of Facial Burns

Initial assessment of all facial burns should start by ruling out inhalation injury and need for intubation.

A history of burns occurring in an enclosed space is a risk factor for inhalation injury. As such, inhalation injury must be ruled out when signs such as expectoration of soot, wheezing, and singed nasal vibrissae are present. If intubation is necessary, care should be taken to secure the endotracheal tube in such a fashion that prevents pressure necrosis. Insertion of a feeding tube should be performed in all patients being intubated and those with burns on greater than 20% total body surface area. This should be secured in a way as to prevent pressure necrosis of the columella. The authors prefer to place a Dobhoff tube in a postpyloric position, when possible, and to secure this with a nasal bridle. Any patient with periorbital burns must have a corneal examination by means of a Wood’s lamp. If injury to the cornea is suspected, an ophthalmology consult for further workup and management is ascertained. Aggressive lubrication of the eyes is considered routine burn care and should be started immediately as part of the initial management of any facial burn.

Once initial assessment of the facial burn has been performed and any airway issues have been addressed, burn wounds of the head and neck should be cleansed with an antibacterial soap. Removal of debris and debridement of any blisters in which the epithelial covers have been disrupted is essential to proper cleansing. Hair-bearing areas of the scalp and face involved in the burn injury should be shaved frequently with electric clippers to keep short. Topical antimicrobials should be placed over the clean burn wound every 6 hours to keep it moist.

Topical Antimicrobials

Following cleansing of the wound, topical antimicrobials should be used as first-line care in burn wound management for prevention and control of wound infections. In choosing a topical antimicrobial agent, the decision should be for an agent that is easy to apply and remove with gentle cleansing, lacks tissue toxicity, is broad spectrum, and has adequate eschar penetration. Creams and ointments are generally preferred to solutions in this area of the body because of the contours of the face and ease of its application.

Silver sulfadiazine cream 1% is effective against gram-positive and gram-negative bacteria, and fungus. It is applied twice daily. The use of silver sulfadiazine cream, however, is limited in facial burns, especially in children younger than 2 years of age, secondary to its potential damaging effect on the eyes and toxicity if ingested.

Mafenide acetate is also highly effective against both gram-positive and gram-negative bacteria. It also has good eschar penetrance, which makes it a good topical antimicrobial for exposed cartilage in full-thickness burns to the ears and nose. Unfortunately, inflammation and pain with application make it a less favorable option for wound care to the rest of the face.

Bacitracin ointment, effective against gram-positive bacteria, is the authors’ topical antimicrobial of choice for burns to the face and scalp and is applied every 6 hours. Bacitracin is less irritating to the eyes, has minimal to no systemic effects, and is easy to remove between applications. Placement of a nonstick dressing, such as a petroleum jelly–impregnated gauze, over the bacitracin between applications is highly effective at providing a moist healing environment for both partial-thickness and full-thickness burns. Mupirocin is useful in patients known to be MRSA colonized.

Management of Partial-Thickness Burns of the Head and Neck

Determining the depth of injury can be very difficult immediately following a burn to the head and neck. Because of the rich vascularity and high density of skin appendages, the face and scalp generally heal quickly with decreased risk of infection and scarring. Burn wounds to the head and neck should be managed expectantly unless they are clearly full-thickness in nature, at which point, early tangential excision and grafting should proceed once the patient is medically able to undergo such an operation. Partial-thickness burns should be reassessed for healing potential around 10 days postburn. Partial-thickness burns usually show significant signs of healing, if not healed, by 14 days following initial injury. This helps to differentiate these wounds from full-thickness injury.

Nonoperative Management of Partial-Thickness Burns

Treatment of partial-thickness burns was historically mostly nonoperative in nature. Frequent dressing changes and daily washing allowed for superficial debridement of the wounds and provided a moist environment for healing. Such nonoperative treatments are still routinely used for partial-thickness burns to the face and scalp with the various topical treatments (see previous discussion). Another approach to the management of partial-thickness burns is by mechanical debridement and the application of skin substitutes.

Skin Substitutes in the Management of Partial-Thickness Burns

Debridement of partial-thickness wounds by tangential excision can result is loss of undamaged skin appendages critical to re-epithelialization. Dermabrasion, using traditional metal burrs on a rotating electric motor or a manual simpler electrocautery scratch pad, is a reliable tool for in the treatment of partial-thickness burns. The use of this technique allows for controlled removal of damaged cells, while protecting underlying intact structures necessary for re-epithelialization. This is especially useful in head and neck reconstruction given the contours of the face, which make tangential excision more difficult than in other areas of the body. Another useful tool for debridement of partial-thickness burns of the head and neck is the water-jet system, which allows for precise and rapid debridement with simultaneous removal of debris. Once this damaged tissue has been removed, a more reliable assessment of burn depth and healing potential can be ascertained.

Following debridement, skin substitutes may be used because their ability to adhere and integrate to the contours of the face decrease the number of dressing changes required during the course of a hospitalization. This, in turn, decreases patient pain and discomfort. In addition, skin substitutes promote rapid re-epithelialization and decrease the risk of infection when compared with conventional topical treatments and dressing changes, and reduce evaporative losses of water, protein, and heat. Skin substitutes that have been well studied for their advantages in healing of partial-thickness facial burns include porcine xenograft, human allograft, human fibroblast-derived temporary skin substitute (TransCyte, Advanced Tissue Sciences, La Jolla, CA, USA), other collagen constructs, and amniotic membranes. Allogenic skin has also been shown to not only increase the rate of re-epithelialization but also decreases the incidence of hypertrophic scarring, thereby improving cosmetic outcome. Amniotic membrane adheres and conforms well to the contours of the face, and has low antigenicity and good antimicrobial potential. It, too, has been shown to increase rate of re-epithelialization.

Management of Full-Thickness Burns of the Head and Neck

Historically, full-thickness burns of the head and neck region were treated with dressing changes until spontaneous separation of the eschar from underlying granulation tissue occurred. At this time, autografting on top of granulation tissue could be pursued. This method often led to hypertrophic scarring because burns that heal after 21 days have greater than double the risk of hypertrophic scarring compared with those that heal between 14 and 21 days. The concept of early tangential excision and grafting was introduced by Janzekovic in 1970 and has become the treatment of choice in head and neck full-thickness burn injury as a way to minimize hypertrophic scarring and improve cosmetic outcomes. Early excision and sheet grafting yields results that permit the burn survivors to return to society and minimize the time off work or out of school.

Because it can be difficult on initial presentation to differentiate between partial-thickness and full-thickness burns of the head and neck, it is recommended to re-evaluate the wounds after 10 days. Most partial-thickness burns show signs of spontaneous healing by this time. If the wound is not likely to heal by 21 days postburn, surgical excision and skin grafting is recommended. Burns that are clearly full-thickness are excised and skin grafted as soon as the patient’s medical status permits. The goal is to have the burn wound treated and skin grafted within 14 days of the burn injury.

In panfacial burns, the eyelids should be excised first, followed by the nose, upper and lower lip, chin, cheeks, and then forehead. The eyebrows should be spared if spontaneous healing will preserve some hair in this area. In facial burn reconstruction, it is important to adhere to the aesthetic unit principle in which small, unburned areas of an aesthetic unit to be excised should be included at the time of resection and grafted as a whole.

Standard tools for tangential excision include the Goulian knife, the dermabrader, scratch pad, curette, and scalpel. Once the wounds have been excised and hemostasis achieved, many investigators advocate a 2-stage approach to reconstruction with allograft placement before skin grafting. Allograft is left in place anywhere from 48 hours to 1 week before skin grafting. The allograft acts as a test to determine if the wound bed is ready for autografting from a microbiology and a vascular consideration. If the allograft is adherent to the underlying wound, the burn has been adequately excised. If it is not, then that area of burn will require further excision or infection treatment before autografting.

The Integra Dermal Regenerative Template (Integra LifeSciences Corporation, Plainsboro, NJ, USA) is a bilaminar structure consisting of a layer of cross-linked bovine collagen and chondroitin-6-sulfate. An outer silastic layer is also used in the first step toward reconstruction of burns of the head and neck. It is meshed and fixed to the wound bed after tangential excision is performed. Once it becomes vascularized, Integra forms a neodermis that is capable of accepting a much thinner autograft. This process takes approximately 2 weeks before autografting is possible. Results from the use of Integra and split-thickness skin grafts, have shown to produce acceptable color match and texture with graft-graft junctures being less evident. Newer formulations of Integra are thinner (without the silastic outer layer) and potentially allow for single-staged reconstruction of a more full-thickness–like graft. The use of Integra and delayed autografting on full-thickness eyelid burns, however, leads to ectropion and is, therefore, not recommended. Full-thickness eyelid burns should be grafted immediately following tangential excision.

Thicker split-thickness skin grafts are generally preferred for the reconstruction of the head and neck, except when using Integra. Skin grafts are harvested at a thickness of 0.018 to 0.025 of an inch in adults and 0.008 to 0.012 of an inch in children. The thicker skin graft decreases the amount of secondary contracture that occurs during healing. The scalp is the donor site of choice when available, followed by the upper back and chest, and, less frequently, the abdomen and thighs. In the case of large total body surface area burns, grafts for the face are obtained wherever adequate skin is available and set aside before harvesting skin graft of the rest of the body.

Treatment of Burns to the Eyelids and Ears

Delayed treatment of full-thickness burns of the eyelids can lead to exposure keratitis and corneal ulceration because the wound contracts and ectropion ensues. Early eyelid release and skin grafting has been shown to reduce the incidence of these complications. Split-thickness skin grafts used for upper eyelid reconstruction fold and drape well compared with thicker grafts. However, full-thickness skin grafts may lead to decreased rates of retraction and ectropion. Full-thickness skin grafts are almost always chosen for lower eyelid reconstruction, again, to decrease the rate of secondary contraction and ectropion of the lower eyelid. Temporary tarsorrhaphies may be necessary to protect the cornea while the grafts mature.

Partial-thickness and full-thickness burns to ears are treated acutely with topical antimicrobials. Mafenide acetate, when applied twice daily, is the treatment of choice for burns to the ears given its superior eschar penetration and prevention of chondritis. For patients who cannot tolerate the painful side effects of this treatment, betadine ointment or silver sulfadiazine can also be applied to the burn eschar. Full-thickness burns to the ears should be managed expectantly, allowing the eschar to spontaneously separate, at which point autografting can be performed over granulation tissue, or local flaps, if available, can be used for coverage of exposed cartilage as needed to maintain 3-dimensional ear contours.

Postoperative Management

Once open burn wounds have healed, there are several therapies in which to minimize scars and assist in their maturation. Topical silicone gel is a mainstay in therapy to encourage scar maturation. Compression therapy is known to minimize hypertrophy of scars. Computer-molded compression masks allow direct pressure to the point of blanching of the scars. Splints are also used to maintain optimal length of scars and prevention of postoperative contractures. Often the neck is splinted in the acute phase in the neutral position and serially with increasing extension to improve range of motion and minimize contracture. Physical therapy and range of motion is rarely started in the emergent phase but is initiated in the acute phase. Massage and stretching are initiated at this time as well. Massage can be used to encourage orientation of the collagen fibers.