Excision of burns of the face

Outcome of Facial Burn Injuries Treated by a Nanofibrous Temporary Epidermal Layer

BACKGROUND

The face is commonly affected in thermal injuries, with a demand for proper recognition and the correct choice of treatment to guarantee optimal aesthetic and functional outcomes. It is highly vascularized and often heals conservatively, highlighting the particular relevance of conservative treatment modalities, many of which require daily re-applications or dressing changes, which can be painful and tedious for both the patient and the healthcare providers. Motivated by encouraging results of a novel temporary nanofibrous epidermal layer, we herein present a case series of this technology in a case series of patients suffering from facial burns and treated in our Burn Center.

PATIENTS AND METHODS

Patients with superficial partial-thickness facial burns and mixed pattern burns, which were treated with SpinCare™, an electrospun nanofibrous temporary epidermal layer, between 2019 and 2021, at our institution were analyzed retrospectively. The Manchester scar scale (MSS) and numeric rating scale (NRS) were used for scar, pain, and outcome evaluation at different time points by five independent board-certified plastic surgeons with profound experience in burn surgery.

RESULTS

Ten patients (m = 9; f = 1) were treated and evaluated retrospectively. The mean age was 38.8 ± years (SD ± 17.85). The mean healing time was 6.4 days (SD ± 1.56). The mean follow-up was 16.4 months (SD ± 11.33). The mean MSS score was 5.06 (SD ± 1.31), and the mean NRS Score for pain was significantly reduced from initially 7 to 0.875 upon application (mean (pre-application) 7 ± 0.7 and (application) 0.875 ± 1.26; p ≤ 0.0001). Patients reported a NRS score of 10 in terms of functional and cosmetic outcomes at their final follow-up appointment. No adverse effects were observed.

CONCLUSIONS

The application of a nanofibrous temporary epidermal layer such as SpinCare™ represents a relatively easy-to-use, well-tolerated, and effective alternative for the treatment of partial-thickness facial burns.

Using Dehydrated Amniotic Membrane Skin Substitute in Facial Burns: Is There a Outcome Difference Between Adult and Pediatric Patients?

INTRODUCTION

Facial burns have significant physical and psychological effects on patients, and minimizing morbidity continues to be a challenge for reconstructive surgeons. Advancements have allowed the development of various skin substitutes. Among these, human dehydrated amniotic skin substitutes represent novel technology, yet their outcome has not been sufficiently studied to guide practice. The objective of our study is to compare the safety of amniotic membrane skin substitutes in the treatment of adult and pediatric facial burns.

METHODS

The authors performed a retrospective review of our institutional burn registry, with 90 burn patients meeting the inclusion criteria. Demographic and outcome measures included age, percentage of total body surface area (TBSA), Injury Severity Score (ISS), and complications (eg, pigmentation, hypertrophic scar, infection, and delayed healing). Paired sample t test and Chi-squared test were used, with significance defined as P < 0.05.

RESULTS

Seventy-seven adults and 13 pediatric patients with facial burns who had received dehydrated amniotic membrane skin substitutes were included in the analysis. The mean age was 40.8 years for adults and 5.6 years for children. Mean TBSA was similar, with 9.6% (1-57%) in adults and 6.0% (2-14%) in children. The mean ISS did not significantly differ between groups (4.0 versus 2.2, P = ns). Pediatric patients with facial burns treated with amniotic membranes had a higher incidence of dyspigmentation relative to adult patients (46.2% versus 9.1%, P ≤ 0.05). Remaining morbidities were not significantly different between adult and pediatric patients. All patients, irrespective of group, healed by the second post-operative week.

CONCLUSION

Dehydrated amniotic membrane skin substitutes are a safe alternative in the treatment of facial burns across all ages.

The Use of Dehydrated Human Amniotic/Chorionic Membrane Skin Substitute in the Treatment of Pediatric Facial Burn

BACKGROUND

Facial burns have lasting physical and psychological effects on pediatric patients. Proper management to minimize morbidities challenges reconstructive surgeons. New technologies allowed the development of skin substitutes such as amniotic and chorionic membranes, yet the use of these skin dressings and their impact on burn outcomes have not been sufficiently studied to guide practices. The objective of this study is to report on the outcomes of dehydrated amniotic membrane as a biologic skin dressing in pediatric facial burn injury compared to cadaveric allografts.

METHODS

Retrospective review of data collected from our institutional burn registry from 2012 to 2016. The study population included patients younger than 16 years with facial burns. Patients between 2012 and 2014 received cadaveric allografts, whereas during 2015 to 2016 patients received dehydrated human amniotic/chorionic membrane as standard treatment. Demographic characteristics and outcome measures were compared between the 2 groups.

RESULTS

Included 30 patients with a mean age of 3.7 years and with an average total body surface area burn of 6.8% (2%-27%). Mean injury severity scores did not significantly differ between both groups, 1.8 in amniotic group versus 2.3 in cadaveric skin group (P > 0.05). There were 4 complications (3 hypertrophic scars and 1 wound infection) in the cadaveric allografts group versus no complications in the amniotic membrane group (P < 0.05).

CONCLUSION

Dehydrated amniotic/chorionic membrane wound dressings are a safe alternative to cadaveric allografts in treating pediatric partial thickness facial burns.

Microsurgical Burn Reconstruction

The treatment of burn-related wounds requires consideration of several factors, including defect size, available donor sites, exposure of critical structures, and the ultimate functional and aesthetic result of reconstruction. Although skin grafts and locoregional flaps are workhorses in burn reconstruction, they have inherent limitations that can directly impact reconstructive outcomes. Microsurgical free tissue transfer represents a viable option for the reconstruction of burn-related wounds in certain patients. Each anatomic region of the body has unique challenges that must be addressed to achieve a successful reconstruction. Therefore, the choice of free flap must be individualized to the wound and patients.

Autologous Graft Thickness Affects Scar Contraction and Quality in a Porcine Excisional Wound Model

BACKGROUND

Texture, color, and durability are important characteristics to consider for skin replacement in conspicuous and/or mobile regions of the body such as the face, neck, and hands. Although autograft thickness is a known determinant of skin quality, few studies have correlated the subjective and objective characters of skin graft healing with their associated morphologic and cellular profiles. Defining these relationships may help guide development and evaluation of future skin replacement strategies.

METHODS

Six-centimeter-diameter full-thickness wounds were created on the back of female Yorkshire pigs and covered by autografts of variable thicknesses. Skin quality was assessed on day 120 using an observer scar assessment score and objective determinations for scar contraction, erythema, pigmentation, and surface irregularities. Histological, histochemical, and immunohistochemical assessments were performed.

RESULTS

Thick grafts demonstrated lower observer scar assessment score (better quality) and decreased erythema, pigmentation, and surface irregularities. Histologically, thin grafts resulted in scar-like collagen proliferation while thick grafts preserves the dermal architecture. Increased vascularity and prolonged and increased cellular infiltration were observed among thin grafts. In addition, thin grafts contained predominately dense collagen fibers, whereas thick grafts had loosely arranged collagen. α-Smooth muscle actin staining for myofibroblasts was observed earlier and persisted longer among thinner grafts.

CONCLUSIONS

Graft thickness is an important determinant of skin quality. High-quality skin replacements are associated with preserved collagen architecture, decreased neovascularization, and decreased inflammatory cellular infiltration. This model, using autologous skin as a metric of quality, may give a more informative analysis of emerging skin replacement strategies.

Late outcomes after grafting of the severely burned face: a quality improvement initiative

Many approaches to surgical management of the severely burned face are described, but there are few objective outcome studies. The purpose of this study was to perform a detailed evaluation of the late outcomes in adult patients who have undergone grafting using a standardized surgical and rehabilitation approach for full-thickness (FT) facial burns to identify areas for improvement in the treatment strategy of authors. This was a prospective observational study in which patients who had undergone grafting for FT facial burns by the senior investigator at a regional burn centre between 1999 and 2010 were examined by a single evaluator. The surgical approach included tangential excision based on the facial aesthetic units, temporary cover with allograft then autografting with scalp skin preferentially, split grafts for the upper eyelid, and FT grafts for the lower eyelid. Rehabilitation included compression (uvex and or soft cloth), scar massage, and silicone gel sheeting. Of 35 patients with facial grafts, 14 subjects (age 43 ± 16 years with 22 ± 21% TBSA burns) returned for late follow-up at 40 ± 33 months (range, 5-91 months). A mean of four facial aesthetic units per patient were grafted (range, 1-9 units), with six full facial grafts performed. Scalp was used as donor in 10 of 14 cases. Scalp donor sites were well tolerated with minor alopecia visible in only one case although the donor site visibly extended slightly past the hairline in two cases. Color match with native skin was rated at 8.8 ± 0.8 of 10 when scalp skin was used compared with 7.5 ± 1.6 with other donor sites (P = .06). On the lip and chin, hypertrophic scars were significantly worse compared with the rest of the facial grafts (Vancouver scar scale 8 ± 2 vs 3 ± 1, P < .01). Sensory recovery was poor with overall moving two-point discrimination at 11 ± 3 mm (range, 4-15 mm), and monofilament light touch was 3.8 ± 0.6. Graft borders were significantly more elevated than graft seams. On the forehead, the most notable problem was a gap between the graft and hairlines of the frontal scalp and eyebrows (range, 0-40 mm). Grafted eyelids required one or more subsequent ectropion releases in the majority of cases. The most common problem for the nose was asymmetry of the nostril apertures. The most problematic late outcomes that the authors identified after facial grafting for FT facial burns included relatively poor sensory return, elevation of graft edges, eyelid ectropion, gaps between grafts and hairline, and marked hypertrophic scarring around the mouth and chin. The results indicate that possible areas for quality improvement include greater attention to the limits of scalp harvest, more attention to pressure application to graft borders and the lip and chin during rehabilitation, greater accuracy in excision and graft placement on the forehead to avoid gaps with the hairlines, and counseling of the patient regarding the high probability of diminished facial sensation.

A multi-staged approach to the reconstruction of a burnt Asian face

This article describes the management of chemical burns to the Asian face with resultant full thickness loss to the right side of the face including the eyelid and nose. We detail the techniques used to reconstruct the face which include skin grafting according to the aesthetic units of the face, accurate placement of junction lines, use of a chondrocutaneous graft to reconstruct the alar grove and scalp strip grafting for eyebrow reconstruction. We obtained a successful result that minimised scar formation in the burnt Asian face.

Surgical excision of the burn wound

Early excision of the burn eschar has been one of the most significant advances in modern burn care. Historical advances in understanding of the pathophysiology of burn injury and the systemic inflammatory response fueled by the burn wound, and refinements in the techniques of tangential and fascial excision, have led to earlier excision and grafting of the burn wound with improvements in morbidity and mortality. Efforts to control blood loss, and good operative planning and attention to special areas, can lead to the safe excision and grafting of large burns.

Tangential excision of burn wounds

Mortality from burns has significantly declined during the last few decades. The decline in mortality is attributed to number of factors that improved over the years including the surgical technique of tangential excision. Since its introduction, the procedure has been under continuous scrutiny in efforts to determine the efficacy of the procedure. Tangential excision must be performed with careful attention to blood loss, patient body temperature, and viable tissue in order to be successful. The procedure has shown signs of improvement of the more conservative methods of burn treatment. The results, however, have some differing efficacy among the different body areas. It has been indicated that tangential excision provides better cosmetic results in facial burns. For hand burns, however, the results have not been significantly better than the conservative methods of treatment.

Pediatric facial burns

Despite major advances in the area of burn management, burn injury continues to be a leading cause of pediatric mortality and morbidity. Facial burns in particular are devastating to the affected child and result in numerous physical and psychosocial sequelae. Although many of the principles of adult burn management can be applied to a pediatric patient with facial burns, the surgeon must be cognizant of several important differences. Facial burns and subsequent scar formation can drastically affect the growth potential of a child's face. Structures such as the nose and teeth may become deformed due to abnormal external forces caused by contractures. Serious complications such as occlusion amblyopia and microstomia must be anticipated and urgently addressed to avert permanent consequences, whereas other reconstructive procedures can be delayed until scar maturation occurs. Furthermore, because young children are actively developing the concept of self, severe facial burns can alter a child's sense of identity and place the child at high risk for future emotional and psychologic disturbances. Surgical reconstruction of burn wounds should proceed only after thorough planning and may involve a variety of skin graft, flap, and tissue expansion techniques. The most favorable outcome is achieved when facial resurfacing is performed with respect to the aesthetic units of the face. Children with facial burns remain a considerable challenge to their caregivers, and these patients require long-term care by a multidisciplinary team of physicians and therapists to optimize functional, cosmetic, and psychosocial outcomes.

The role of free-tissue transfer for head and neck burn reconstruction

BACKGROUND

The reconstruction of head and neck burns is challenging, traditionally involving skin grafting and local flaps. Free flaps have improved in versatility and variability in recent years, and are now among the techniques used for burn reconstruction.

METHODS

Thirty-six free flaps for 32 patients with cervicofacial burns were reviewed retrospectively over a 17-year period (1989 to 2005) to determine indications, methods, and outcomes.

RESULTS

The mean patient age was 31 years. Thirteen flaps were transferred to the neck and 23 to the face. The main indication was contractures or hypertrophic scarring followed by exposed bone or cartilage. The majority of flaps were transferred for secondary reconstruction. The free flaps most frequently used were the anterolateral thigh (31 percent), scapular/parascapular (31 percent), and radial forearm (17 percent). Fourteen were prefabricated, one was prelaminated, and 15 were tissue-expanded. A total of 34 flaps (94 percent) were successful. There were no deaths, two donor-site complications, a 17 percent tip necrosis rate, and a 6 percent flap infection rate. The median hospital stay was 6 days after free flap transfer. Patients were followed for at least 1 year, and 64 percent of flaps needed further debulking or sculpting.

CONCLUSIONS

Free tissue transfer is a valuable tool in head and neck burn reconstruction. It can be used safely and effectively with minimal morbidity in selected patients.

Initial Reconstruction of Sustained Neck and Facial Burns

Approximately 50% of burn injuries involve the neck and head region. Because both appearance and function must be taken into account with burns of this area, several consecutive reconstructions will be performed. With a focus on improving outcome after burn injury, we underline the method of grafting as a very important element in primary surgery. With our special excision and grafting technique, we aim to achieve a reconstruction that deals with mobility and aesthetics. Consequently, necessary reconstructive procedures may be fewer and of less magnitude. We describe this surgical technique in detail. In this study we surgically treated 39 patients with sustained facial and neck burns. For 22 patients this surgical treatment circumvented the need to perform any secondary reconstructions. The proposed treatment involves a special grafting technique after pretreatment with a topical agent in combination with early pressure therapy.

Evidence for the link between healing time and the development of hypertrophic scars (HTS) in paediatric burns due to scald injury

The relationship between burn depth, healing time and the development of hypertrophic scarring (HTS) is well recognised by burn surgeons but is seldom mentioned in the published literature. We studied 337 children with scalds whose scars were monitored for up to 5 years. Overall HTS rates were found to be: under 10 days to healing=0%, 10-14 days=8%, 15-21 days=20%, 22-25 days=40%, 26-30 days=68% and over 30 days=92%. In the conservatively treated group the HTS rates are: under 10 days=0%, 10-14 days=2%, 15-21 days=20%, 22-25 days=28%, 26-30 days=75% and over 30 days=94%. If skin grafting is undertaken there is a much higher incidence of HTS in the 10-14 days group: 10-14 days=33%, 15-21 days=19%, 22-25 days=54%, 26-30 days=64% and over 30 days=88%. We conclude that there is a low risk of HTS formation in scalds healed before 21 days, and that surgery should be reserved for scalds likely to take more than 21 days to heal.

The Scalp Is an Advantageous Donor Site for Thin-Skin Grafts: A Report on 945 Harvested Samples

BACKGROUND

Thin-skin grafts taken from the thigh or buttock take a long time to heal and leave permanent scars.

METHODS

The authors conducted a retrospective study based on their experience with 945 thin-skin grafts (0.2 mm) taken from the scalps of 757 adult patients between January of 1999 and December of 2003.

RESULTS

Of the 757 patients, 89 had grafts taken repeatedly from the scalp. The mean healing time was 6.2 days for a single harvest and 10.2 days for repeated (same hospitalization) harvests. During follow-up, eight patients had microalopecia and three developed "concrete scalp deformity." Of these 11 patients, eight had undergone repeated harvests. None of the other patients had any scarring; they were completely healed by day 15.

CONCLUSIONS

The results of this study confirm the rapidity of scalp healing compared with other donor sites. Providing patients with clear, detailed explanations helps minimize the psychological impact of having their heads shaved, and a rigorous technique can contain the two major potential risks: hemorrhage and alopecia. The adult scalp seems to be a donor site to be exploited whenever possible.

Early excision and grafting of face and neck burns in patients over 20 years

Although excision and grafting of burns has become common and standard, many surgeons have been reluctant to excise and graft face burns. In fact, we could find photographic results at 1 year after grafting of only eight patients in the English literature. We began excision and grafting of face burns in 1979 and presented our first 16 patients in 1986 in this journal. With encouragement from Janzekovic and Jackson, we continued and have now used essentially the same procedure for more than 20 years in approximately 100 patients and, from this large series, are able to present outcomes. From January of 1979 to May of 1999, we performed excision and grafting on 91 patients with deep face burns. Data were recorded and 35-mm photographs were obtained throughout the 20-year period. We reviewed that database and the slide files of these patients. We found 45 patients with complete photographic sets including 1-year follow-up. Since, in our opinion, there is no useful, objective measure of appearance, we decided to simply publish all 45 sets of complete photographs, permitting the reader to subjectively form an opinion of the outcome of this procedure. The results are all shown as "full" face burns and two "partial" face burns. We continue to believe that early excision and grafting is indicated for face burns that will not heal within 3 weeks and that the procedure yields results that permit the burn victims to return to society and minimizes the time off work or out of school.

The management of white phosphorus burns

Phosphorus burns are a rarely encountered chemical burn, typically occurring in battle, industrial accidents, or from fireworks. Death may result even with minimal burn areas. Early recognition of affected areas and adequate resuscitation is crucial. Amongst our 2765 admissions between 1984 and 1998, 326 patients had chemical burns. Seven admissions were the result of phosphorus burns. Our treatment protocol comprises 1% copper sulfate solution for neutralization and identification of phosphorus particles, copious normal saline irrigation, keeping wounds moist with saline-soaked thick pads even during transportation, prompt debridement of affected areas, porcine skin coverage or skin grafts for acute wound management, as well as intensive monitoring of electrolytes and cardiac function in our burns center. Intravenous calcium gluconate is mandatory for correction of hypocalcemia. Of the seven, one patient died from inhalation injury and the others were scheduled for sequential surgical procedures for functional and cosmetic recovery. Cooling affected areas with tap water or normal saline, prompt removal of phosphorus particles with mechanical debridement, intensive monitoring, and maintenance of electrolyte balance are critical steps in initial management. Fluid resuscitation can be adjusted according to urine output. Early excision and skin autografts summarize our phosphorus burn treatment protocol.

Reconstruction of the aesthetic units of the face with microsurgery: experience in five years

Since the description of the aesthetic units of the face by González-Ulloa, surgical attempts have been made to achieve excellent results with skin grafts, pedicled flaps, and free flaps. At our institution, we preferentially use microsurgical replacement of the aesthetic units independent of the etiology. The objective of this article is to present a retrospective review of the outcome of patients who underwent these procedures. The etiology, the choice of the procedure, and the functional and aesthetic results are assessed. We suggest the main features according to the results obtained. In this retrospective review, 43 procedures in a 5-year period are analyzed and the results reported. We conclude that the operative procedure is both technically simple and effective over the long term.

Management of burn wounds with prompt excision and immediate closure

The past 30 years have been witness to significant improvements in the overall care and prognosis of those suffering burn trauma. At the heart of this success is an aggressive approach to burn wounds. This approach, which is detailed in this review, involves early operative removal of devitalized tissue and biological coverage of resultant wounds, with particular attention to wounds in specialized areas.

Assault inflicted by hot water

Assault inflicted by hot water is uncommon although such injuries have been reported from many parts of the world. The patient characteristics, burn distribution and outcome in 127 patients who had been intentionally assaulted with hot water during a 7 1/2 year period are reported. More than half of the males were assaulted by their wives. The female was often assaulted by her spouse or another family member. Most patients came from lower socioeconomic groups. The average burn surface area was 13.7 per cent (range 1-45 per cent). The upper part of the body was much more frequently burned than the pelvic and lower limb areas (12 per cent). Males (94) were assaulted more commonly than females (33). Eighty-four patients suffered partial skin thickness burns requiring debridement and skin grafting. The average hospital stay was 17 days (range 1-61 days). Upper body hot water burns in adults should raise the possibility of assault in the minds of attending medical personnel, especially where predisposing factors exist (alcohol abuse, lower socioeconomic strata, poor education). Most patients sustain partial skin thickness burns and will require debridement and grafting. Psychosocial factors require investigation and professional intervention.

Subcutaneous instillation of donor sites in burn patients

A simple technique of powered subcutaneous instillation of split-thickness skin graft donor sites in burn patients and other plastic surgical patients has been developed. The necessary equipment required, including a standard pneumatic tourniquet, arterial pressure bags and spinal needles, is available in any plastic surgery operating theatre. In over 300 cases in which it has been employed, no complications have been encountered.

Primary pressure grafts in early reconstruction of deep facial burns

The face is an area of great cosmetic importance where the repair of deep burns is particularly delicate, as both appearance and function must be taken into account. In order to improve the aesthetic prognosis of full skin thickness facial burns, a primary pressure graft technique was used in eight patients. Early excision was carried out during postburn day 3 and after good-quality granulation tissue was obtained around day 10, a full skin thickness graft was applied. Pressure was applied to the graft and maintained for 10 days. The grafts took successfully in all patients with very satisfactory cosmetic results. This is an original technique as it replaces burned tissue at a very early stage with tissue which is normal in thickness and quality.

Burn depth: a review

Despite the plethora of technologic advances, the most common technique for diagnosing burn depth remains the clinical assessment of an experienced burn surgeon. It is clear that this assessment is accurate for very deep and very shallow burns. But since clinical judgment is not precise in telling whether a dermal burn will heal in 3 weeks, efforts to develop a burn depth indicator are certainly warranted to accurately determine which dermal burns to excise and graft. This review summarizes the considerable literature in which a variety of techniques to determine burn depth have been used.

Expanding oral angle plasty using a subcutaneous pedicle flap to correct severe microstomia after extensive facial burns

Expanding oral angle plasty using a subcutaneous pedicle flap to correct severe microstomia due to extensive facial scar contractures is described. This technique is especially suited for the elderly, who are unable to tolerate large skin grafting of the face, and for patients with insufficient normal donor skin to undertake extensive correction of scar contractures.

Face burn reconstruction--does early excision and autografting improve aesthetic appearance?

Despite improvements in functional rehabilitation secondary to better control of scar and contractures, aesthetic rehabilitation of the extensively burned face has remained a difficult problem. This study was undertaken to evaluate both technique and aesthetic results of early excision and split thickness autografting (STAG) of full skin thickness face burns. Twenty-five patients with full skin thickness face burns were operated on between days 4 and 14 post-burn. Thirteen patients had excision and STAG in one stage. Twelve patients had a two-stage procedure-excision and coverage with a biological dressing followed 24-72 h later by STAG. Seven of these patients had a pressure dressing in the form of a silicone face mask applied at the second stage. Early cosmetic results were encouraging in all patients. Twenty-five per cent of patients later required either contracture release or skin resurfacing. Preliminary results are encouraging and warrant evaluation by surgeons at other centres. When early excision of full skin thickness face burns is undertaken, cautious optimism as to the ultimate aesthetic result, both by the surgeon and the patient, is advisable.