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Chapter 6. Burn Wound Management
Other types of synthetic skin substitutes are AlloDerm
177
®
Integra®, Biodegradable Temporizing Matrix (BTM®), and
Matriderm®. These types of skin substitutes belong in the
group of acellular skin substitutes which function as a dermal
layer. These skin substitutes are made from natural biological
materials and collagen. The silicone membranes of these dermal substitutes serve as the epidermis until removed and
replaced with autograft skin.
It is important to recognize that several types of skin substitutes are available for use that cater to a variety of needs.
Whereas some skin substitutes are more suitable for replacing solely the dermal layer, some are used to replace both the
dermal and epidermal layers. Additionally, some skin substitutes are composed of different materials as they may help
address other complications specific to the patient.
Conclusion
Acute management of a burn patient is most critical within
the first 72 h of injury. It cannot be overemphasized that
proper healing begins in the emergency department.
For each burn patient, the initial assessment is important
since this process will indicate the magnitude and type of burn,
additional injuries, approximate healing time, and length of
hospital stay. All of these factors play a significant role in determining the most appropriate treatment needed for the patient.
Usually, minor burns (generally less than 10% TBSA partialthickness burns) may be treated as an outpatient unless otherwise stated by the ABA’s Burn Criteria. Patients with burns
involving more than 10% TBSA or those with full-thickness
injuries, however, can experience infection, leading to hospitalization and surgery. Treatment of shock, pain relief, managing
airway injuries, and addressing the care of additional trauma
occur before management of the burn wound.
At times, certain injuries may benefit from escharotomy
before transfer to a burn center to prevent circulatory and
pulmonary complications from compression of the tissues.
,
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P. J. South et al.
Assessing for an escharotomy before transfer to a burn center is crucial. Additionally, early burn excision and grafting
should begin promptly as it has proven to decrease the length
of hospital stay, morbidity, mortality, and bacterial colonization [28]. When covering the wound, there are many dressing
methods to choose from. Wound care should be tailored to
individual patients as this care will significantly impact the
wound-healing time.
References
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world. Harvard University Press; 1975.
2. Gurlt EJ.Geschichte der Chirurgie und ihre Ausubung, Vol. 1.
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3. Bull JP, Fisher AJ. A study of mortality in a burns unit:
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org/10.1097/00000658- 195403000- 00002.
4. Wolf SE, Rose JK, Desai MH, Mileski JP, Barrow RE, Herndon
DN. Mortality determinants in massive pediatric burns. An
analysis of 103 children with > or = 80% TBSA burns (> or =
70% full-thickness). Ann Surg. 1997;225(5):554–65; discussion
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5. Zulkowski K. Wound terms and definitions [Guide]. WCET J.
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6. Wallace HA, Basehore BM, Zito PM.Wound healing phases. In
StatPearls; 2021. https://www.ncbi.nlm.nih.gov/pubmed/29262065
7. Coger V, Million N, Rehbock C, Sures B, Nachev M, Barcikowski
S, Wistuba N, Strauss S, Vogt PM. Tissue concentrations of
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www.who.int/surgery/publications/Burns_management.pdf
9. Hudspith J, Rayatt S. First aid and treatment of minor
burns. BMJ. 2004;328(7454):1487–9. https://doi.org/10.1136/
bmj.328.7454.1487.
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10. Tenenhaus M, Rennekampff H-O. Treatment of superficial
burns requiring hospital admission; 2021. https://www.uptodate.
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12. Greenhalgh DG.Sepsis in the burn patient: a different problem
than sepsis in the general population. Burns Trauma. 2017;5:23.
https://doi.org/10.1186/s41038- 017- 0089- 5.
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14. Zhang L, Labib A, Hughes PG. Escharotomy. In: StatPearls;
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pubmed/28613546
16. Pruitt BA Jr, Dowling JA, Moncrief JA.Escharotomy in early
burn care. Arch Surg. 1968;96(4):502–7. https://doi.org/10.1001/
archsurg.1968.01330220018003.
1 7. White CE, Renz EM. Advances in surgical care: management
of severe burn injury. Crit Care Med. 2008;36(7 Suppl):S318–24.
https://doi.org/10.1097/CCM.0b013e31817e2d64.
18. Tiong W.On scene first aid and emergency care for burn victims.
Int Public Health J. 2012;4:3–24. https://www.researchgate.net/
publication/269701993_On_Scene_First_Aid_and_Emergency_
Care_for_Burn_Victims
19. Barret JP, Herndon DN. Effects of burn wound excision on bacterial colonization and invasion. Plast Reconstr
Surg. 2003;111(2):744–50; discussion 751–742. https://doi.
org/10.1097/01.PRS.0000041445.76730.23.
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s0305- 4179(97)00117- 4.
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org/10.1016/j.burns.2016.05.013.
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down the knife: a systematic review of burns excision tools of
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JA. Early excision and grafting vs. nonoperative treatment of burns of indeterminant depth: a randomized prospective study. J Trauma. 1983;23(11):1001–4. https://doi.
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25. Munster AM, Smith-Meek M, Sharkey P. The effect of early
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gov/pubmed/31869181
28. Goswami P, Sahu S, Singodia P, Kumar M, Tudu T, Kumar A,
Sinha PK.Early excision and grafting in burns: an experience in
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Chapter 7
Treatment ofFacial Burns
AlenPalackic, RobertP.Duggan, RahulShah, JongO.Lee,
andLudwikK.Branski
A. Palackic
Department of Surgery, University of Texas Medical Branch,
Galveston, TX, USA
School of Medicine, University of Texas Medical Branch,
Galveston, TX, USA
e-mail: alpalack@utmb.edu
R. P. Duggan
Division of Plastic, Aesthetic and Reconstructive Surgery,
Department of Surgery, Medical University of Graz, Graz, Austria
e-mail: rpduggan@utmb.edu
R. Shah
School of Medicine, University of Texas Medical Branch,
Galveston, TX, USA
Department of Medicine, Vanderbilt University Medical Center,
Nashville, TN, USA
e-mail: rahul.shah@vumc.org
J. O. Lee
Department of Surgery, University of Texas Medical Branch,
Galveston, TX, USA
Shriners Children’s Texas, Galveston, TX, USA
e-mail: jolee@utmb.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
J. O. Lee (ed.), Essential Burn Care for Non-Burn Specialists,
https://doi.org/10.1007/978-3-031-28898-2_7
181
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A. Palackic et al.
L. K. Branski (*)
Department of Surgery, University of Texas Medical Branch,
Galveston, TX, USA
Division of Plastic, Aesthetic and Reconstructive Surgery,
Department of Surgery, Medical University of Graz, Graz, Austria
Shriners Children’s Texas, Galveston, TX, USA
e-mail: lubransk@utmb.edu
Introduction
The human face is vital for communication, allowing for the
transmission of nonverbal information and subtle emotions.
Furthermore, our faces process numerous sensory inputs, facilitating our perception of the outside world. The face has a unique
and complex anatomy, consisting of skin, fat, muscle, and skeleton encasing and supporting sensory structures such as the eyes,
the nose, and the ears. Facial burns can be truly devastating.
Obliteration of facial landmarks, burn scar contractures, and loss
of sensory structures may significantly impair how a patient
interacts with the world. The resulting pain, edema, and scarring
can lead to facial cosmetic and functional deformities and lasting
physical and psychological impairment [1, 2].
Optimal care of the burned face is lifesaving and helps
maximize future cosmetic and functional results. In general,
care consists of the primary assessment, airway control, and
wound care. Later, postburn management focuses on scar
management, reconstruction, and rehabilitation. Because
other vital structures such as the eyes, ears, and the upper and
lower respiratory tracts are commonly involved, the initial
management of the injury can become particularly challenging, requiring an intensive, multidisciplinary effort. The face is
divided into distinct aesthetic units and subunits, first
described by Gonzalez-Ulloa in 1987 [3]. These aesthetic
units play a vital role in the surgical management of the
burned face, in placement of skin grafts and other reconstructions [4, 5]. Facial burn management aims to restore the facial
subunits, achieve a cosmetically satisfactory symmetric face,
and maximize the function of dynamic facial expression [6].
Chapter 7. Treatment ofFacial Burns
This chapter aims to summarize and discuss the different
approaches for the treatment of facial burns.
183
Anatomy andPathophysiology ofFacial
Burns
Skin is vulnerable to numerous environmental insults. Injuries
can be caused by exposure to heat, cold, radiation, chemical,
or electrical sources. Most commonly, though, burns are
caused by thermal insults from liquids or flames [7, 8]. The
face is commonly uncovered, leaving it more vulnerable to
injuries [9]. The skin acts as the primary barrier against ultraviolet radiation, temperature extremes, toxins, and mechanical trauma. Furthermore, it functions as a sensory organ,
mediates immunologic surveillance, and aids in thermoregulation and fluid homeostasis [1, 10].
The skin consists of the epidermis and the dermis. The
severity of a burn injury is classified by the depth of tissue
involved. Accurate assessment of burn extent and depth is
critical for determining the level of care required in the acute
setting and the need for surgical intervention. Burn injuries
that solely affect the epidermis are classified as superficial
burns (first-degree). First-degree burns can be painful and
cause the skin to become erythematous. While painful, these
burns heal spontaneously without scarring. Partial-thickness
burns involve injury down to the dermis. Superficial partialthickness burns (second-degree) are painful, require topical
wound care, typically do not scar, and do not require surgical
procedures. Deep partial-thickness burns (second-degree)
are less painful due to the destruction of pain receptors, drier
than superficial partial-thickness burns, may require surgery,
and are more prone to scarring. Full-thickness burns (thirddegree) extend through the dermis, require skin grafting, and
are at high risk for infections. Fourth-degree burns involve
underlying structures such as muscle or bone [7].
Unique anatomical aspects at different depths of the
facial skin are important in healing. Wound healing depends
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A. Palackic et al.
on several factors, including epithelial cell proliferation and
migration of epidermal appendages. The face and the scalp
contain a high concentration of these appendages, including
sebaceous glands, apocrine glands, and hair follicles. In the
face, these structures are usually localized in the deeper
dermis and the underlying subcutaneous tissue. The high
concentration and density of appendages in the deeper
areas provide a great capacity to re-epithelialize spontaneously [1, 10].
When a thermal insult occurs, local blood supply influences
the depth of the burn. The face is well vascularized. The
greater the blood supply, the better an area can disperse heat,
reducing burn depth and severity [9]. Due to the vascularity
of the face, significant blood loss occurs with excision of
burns, which has to be taken into consideration for surgical
interventions [11].
The skin’s thickness and flexibility affect overall burn depth
and the development of complications such as contractures.
Compared to the skin on the lips and eyelids, most facial skin
is relatively thick. The skin on the forehead mostly sits on
muscle and bone and is not very pliable, so it does not tend to
contract after severe burn injuries. The skin on the face and
the neck mostly overlies muscles and fat and is highly flexible.
When burned, it tends to lead to contractures of the deeper
layers of the skin [9]. The eyelids are often involved in severe
facial burn injuries. The blink reflex protects the eye and the
margin of the eyelid so that only the skin is exposed to the
offending agent. Deep burns and scar contracture can result in
ectropion, leading to incomplete eye closure. Ectropion
increases the risk for desiccation and corneal ulceration leading to perforation and a threat to vision [4]. The nose and the
ears consist of bony structures and cartilage, which are poorly
vascularized with thin overlying skin. Deep burns in this area
can expose the underlying structures and lead to vital tissue
loss and deformity. Burn injuries to the nose, eyelids, and ears
represent a significant challenge in the field of reconstructive
burn surgery [1].
Chapter 7. Treatment ofFacial Burns
185
Inhalation Injury
Inhalation injury refers to tissue damage to the respiratory
tract and the lungs following thermal or chemical insult. These
types of injuries are common in severe facial burns [12]. The
potential for concomitant inhalational injury in facial burn
must be considered, and failure to identify inhalational injury
expediently can be life threatening. Several studies have
shown that patients with burn injuries experience more significant morbidity and mortality when there is concomitant
inhalation injury [13–15]. Clinical suspicion of inhalation
injury is suspected by certain risk factors, such as burns including the face and neck, singed facial or nasal hair, altered voice,
stridor, oral or nasal soot deposits, and carbonaceous sputum.
Due to edema, the most immediate threat from inhalation
injury is upper airway obstruction [16]. Acute upper airway
obstruction occurs in 20–33% of hospitalized burn patients
with inhalation injury, which can rapidly progress from mild
pharyngeal edema to complete upper airway obstruction [17].
Furthermore, patients without significant airway edema may
rapidly decompensate when fluid resuscitation begins.
In general, there are three primary mechanisms and causes of
inhalation injuries. First, direct thermal trauma can involve the
upper respiratory tract and, rarely, subglottic structures [18]. The
upper respiratory tract protects the structures distally from
extreme heat or cold as it serves as a heat exchanger [12].
Second, smoke inhalation can pass the glottis. Chemical irritants
are present in smoke, and the severity of the trauma is determined by the length of exposure, chemical composition, and the
size of the particles. Third, systemic toxicity may occur when
carbon monoxide or cyanide is present in the inhaled gases [12].
The diagnosis of inhalation injuries is challenging and is
typically based on the physical examination, the patient history, and burn mechanism and bronchoscopy. Regarding the
patient history, information about the mechanism of injury,
the exposure, and the combustion source are crucial for
diagnosis. For instance, blast injuries can indicate injuries
distal to the larynx, and the source of combustion can identify
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A. Palackic et al.
particulate and chemical irritants. Tools other than physical
examination and patient history are also often used to support the diagnosis of inhalation injury. Pulse oximetry, arterial
blood gas analysis, and chest X-ray should be carried out as a
baseline. However, they are insensitive tools for lung injuries
in the initial phase of the trauma, as the inflammatory infiltrate occurring in response to injury may take one to two days
to develop [12]. The flexible fiberoptic bronchoscopy directly
visualizes the tissue damage and remains the “gold standard”
to confirm inhalation injuries [19].
The treatment of inhalation injuries is not specific, depends
on various factors, and primarily consists of supportive care.
Initially, the focus is on airway management. There are multiple indications for prophylactic and early intubations.
Intubation can be lifesaving for patients with burns to the
face and inhalation injuries. Nasal intubation may be preferred in patients with partial-thickness burns. Patients with
severe burn (≥30% total body surface area [TBSA] or fullthickness burns of the face) may require long-term ventilation, which may be managed by tracheostomy. This allows
better access for treatment of the face and requires less sedation [1, 12, 20].
Management ofFacial Burns
Facial burn can be devastating and may result in a change in
appearance, scar formation, functional impairment, and psychiatric disability. Deep burns can require long-term rehabilitation and reconstructive procedures. With an accurate
and swift treatment strategy, wound healing and scar prevention can be improved, and further follow-up procedures
avoided.
The general approach for treating facial burns is similar
to that of the rest of the body. The treatment strategy
depends on the depth and size of the burn. Superficial
partial- thickness burns are treated conservatively, as they
heal spontaneously, re-epithelialize on their own within
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