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Chapter 7. Treatment ofFacial Burns
187
14days, and have a low risk of significant scarring. Conversely,
full-thickness burns require excision and skin grafting.
Wounds of undetermined depth pose a major challenge for
the effective treatment of burns, as they may or may not
heal within 21 days. Determining the exact burn depth is
challenging upon the initial examination but is an integral
component of initial management. A delay in re-epithelialization by 2–3 weeks dramatically increases the risk for
hypertrophic scarring [21]. Decades ago, burn wounds were
commonly treated conservatively with daily wound care
because it was postulated that early excision and skin grafting of the face should be avoided [22–24]. Nowadays, most
authors recommend early surgical intervention between 10
and 14days to achieve the best cosmetic outcome in fullthickness facial burns [1, 25, 26]. In severe facial burn injuries, burn severity and depth are not uniform across the
injured area. When to excise and graft a wound are crucial
in the treatment regime and the patient’s outcome.
In the acute setting, after admission to the hospital,
patients undergo initial cleansing with an antiseptic prior to
debridement of the necrotic tissue and blister. This facilitates the assessment of the depth of the burn wound [27].
Superficial partial-thickness burn wounds are treated with
antimicrobial agents with the goal of re-epithelialization
within 14days. Antimicrobial agents play an essential role
in the management of facial burns as they control microbial
burden as well as superficial infections that may slow healing or give rise to systemic disease [27]. Ideally, the topical
antimicrobial has broad-spectrum coverage, limited toxicity, and adequate local eschar penetration without systemic
absorption. Products that are inexpensive and have a long
shelf life are also desirable [27, 28]. Antimicrobials should
be applied several times a day to keep the wound moist.
The face should be cleaned at least once a day to reduce the
risk of infection. There are many different topical antimicrobial agents used to treat facial burns. Topical antibiotic
ointments such as bacitracin zinc and polymyxin B sulfate/
bacitracin zinc are antimicrobial agents that are commonly
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A. Palackic et al.
used in partial-thickness burns. They are easy to apply and
remove and lack in tissue and systemic toxicity [27]. Several
antimicrobial, biologic dressings are available that aid epithelialization in partial- thickness burns and protect against
desiccation and infection [29].
Management ofDeep Facial Burns
Early excision and grafting are compulsory in full-thickness
burns. Partial-thickness burns can be treated conservatively
but must be assessed frequently. Several studies demonstrate the increasing prevalence of hypertrophic scarring in
burns taking longer than 21 days to heal completely [30].
Therefore, delayed healing leads to the need for additional
reconstructive procedures. If healing within 21days can be
anticipated, daily wound care should be continued until
healing is complete. If it is clear the wound will not heal
within 21days, the patient should be considered for excision
and grafting [31].
Several factors must be considered once the decision is
made to excise and graft the wound. Procuring a graft from
a donor site with similar color and quality as the face is
crucial for long-term cosmesis. Skin from unburned areas of
the scalp generally has the best color match but carries a
risk of transferring unwanted hair to the face [4, 9]. As an
alternative, one can procure a skin graft from the upper
back. Skin grafts placed on the face must be unmeshed [4].
Skin grafting to the face also must take into consideration
the aesthetic facial units and subunits. Scars at the junctions
of these units are less noticeable; therefore, any surgery
aims to place incisions, or skin graft seams, at the junctions
[9]. The excision can be performed with various instruments, but a Goulian knife/Weck blade is used for the
majority of the face. The excision should be at a uniform
depth in mixed burn areas. Significant blood loss may occur
with excision of the face. Therefore, it is vital to ensure that
blood products are readily available [1, 9, 31]. To facilitate
Chapter 7. Treatment ofFacial Burns
hemostasis, topical epinephrine can be helpful. Furthermore,
hemostasis can be achieved by electrocautery [4]. Other
studies have reported fibrin sealant as an adjuvant tool to
control hematoma formation in facial burn surgeries [27, 32,
33]. Meticulous hemostasis of the recipient site is critical as
hematoma is an important cause of graft failure, necessitating further operations and delaying wound closure [9].
After excision, it is crucial to decide whether the wound
bed is ready for autografting or whether temporary wound
coverage is more appropriate. When accurate excision and
hemostasis can be ensured, immediate placement of autograft is feasible [31]. If not, the use of an allograft or dermal
substitute can be indicated as the initial coverage.
When a patient experiences a full-thickness facial burn, the
severity and extent of additional burns inform whether or not
the face receives immediate coverage. Following excision of
the face, allograft can be used as temporary coverage. After a
few days, a second operation is performed to evaluate the
allograft. If it is adherent and undergoing vascularization, the
face can be covered with an autograft. The use of dermal substitutes as temporary coverage allows for the use of thinner
donor skin and may reduce the scarring. We, at times, use
dermal substitutes such as Biodegradable Temporizing Matrix
(BTM) (Polynovo Biomaterials Pty. Ltd., Australia). BTM is a
dermal matrix composed of three layers: a biodegrading foam,
a bonding layer, and a sealing membrane. This matrix prevents
wound contraction while promoting re- epithelialization [34,
35]. BTM requires a minimum of 2–3 weeks for vasculariza-
tion before covering the face with autograft skin [9].
189
Scar Management oftheFace
Conservative Approach
Facial burn injuries are devastating and can lead to a longterm physical and psychosocial disability. Implementing an
early scar management regimen in the rehabilitation phase is
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A. Palackic et al.
crucial. The most commonly used noninvasive methods are
massage therapy, pressure therapy, and the local application
of silicone sheets. The application of silicone gel has been
used since the 1980s and has become the standard of care in
plastic surgery. In the early phase of healing, silicone gel
application seems to positively impact the remodeling process [36]. It softens, improves elasticity, and decreases hypertrophy of the scars. Silicone sheets create a hydrated
environment, which then decreases fibroblast activity and
impair scar development. Furthermore, a hydrated environment may decrease nociceptor activity in the scar and
decrease neurogenic inflammation driving hypertrophic scarring [37]. Face masks are used as pressure therapy, usually in
deeper burn injuries. The benefits of the combination of pressure therapy and silicone gel have also been reported [38, 39].
Surgical Approach
Although there have been big advancements in the
conservative approach, surgery still remains the most used
treatment approach when dealing with facial burn scars. Each
scar and each anatomical region have to be evaluated
individually. In the acute phase (within first months), we
focus on anatomical regions that may impair the function due
to contractures, such as the mouth, the eyelid, and the neck.
In the late stage (months to years postburn), we commonly
follow the reconstructive ladder and also consider combining
surgical techniques with laser therapy and corticosteroids if
needed. Burn scar contractures of the face are commonly
treated with tissue rearrangement techniques in combination
with ablative carbon dioxide (CO2) laser treatment.
Laser Therapy
The most applied laser in the main body of the literature is
the fractional CO2 laser (The UltraPulse® Lumenis). This is
an ablative fractional resurfacing (AFR) laser with differ-
Chapter 7. Treatment ofFacial Burns
ent setting options: ActiveFXTM (lowest energy and highest density) and DeepFXTM (balance between energy and
density). These two settings are commonly applied for
superficial and deep treatments, respectively. The
ActiveFXTM and DeepFXTM fractional CO2 lasers can
also be combined in one single session, respectively.
Several studies show that the ablative fractional laser
improves the scar’s height, volume, thickness, and overall
texture [40, 41]. Hypertrophic scars with red or raised
appearance are commonly treated with intense pulsed
light (IPL). In our experience and intralesional corticosteroid injections, typically with triamcinolone (Kenalog
10 mg or 40 mg Bristol Myers Squibb, New York City,
NewYork, USA) is beneficial. Scars with intense pruritus
are also considered for IPL therapy or fat grafting. The
surgeon should also consider applying these approaches in
multiple sessions with a break of 6–8 weeks in between
sessions. This allows the wound to heal and time for observation of the laser treatment benefits.
191
Burn Reconstruction ofAnatomical Regions
As aforementioned, the treatment strongly depends on the
anatomical region. The neck is the most challenging area to
treat in terms of contractures. A simple, one-stage application
of split-thickness skin graft (STSG) will most likely result in
secondary contractures. Other common approaches involve
bioartificial skin substitutes combined with STSG.The commonly applied Integra Dermal Regeneration Template offers
great aesthetic result; however there are reports of contracture recurrence in 50% of cases [42]. The Biodegradable
Temporizing Matrix (BTM) plus STSG is another bioartificial skin substitute that may potentially better prevent contracture recurrence. In our experience, a possible approach to
prevent contractures is a two-stage approach with the French/
McCauley technique with surgical release plus allograft skin
grafting, followed by second-stage grafting with thick STSG
from the back.
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A. Palackic et al.
Scalp alopecia is also a very commonly treated condition
postburn. Smaller defects can be treated with tissue rearrangement techniques. If the alopecia is too large, we use tissue expansion to increase the surface area of the hair-bearing
scalp gradually. Later, the expander is removed, and scarred
tissue is excised, with the area of alopecia now being covered
by the expanded scalp.
Scarring and contractures in the perioral region can lead
to long-term functional deficits with impairment of speech,
eating, and facial expression. Local V-Y advancement flaps
are applied to release the commissures around the mouth.
Upper lip eversion is commonly treated with scar release,
excision, and full-thickness skin grafting. Similarly, we treat
lower lip eversion with excision and full-thickness skin
grafting.
One of the most common early complications in the face
postburn is keratopathy due to eyelid ectropion. The reconstruction should be an early priority as it reduces the risk
for keratopathy. For the reconstruction of eyelids, we
always use a full-thickness skin graft for the lower lid and
thick STSG for the upper lids. Donor skin for the graft
should match the color. The pre- and postauricular regions
are preferred as donor sites; however, as they are often
burned as well, other sites including the supraclavicular
region and the groin are commonly used as grafts and
match the color and texture.
The reconstruction of the nose represents a challenging
area to treat. Local tissue rearrangement techniques are limited due to surrounding burns and grafts often do not match
the color nor texture. The nasal inferiorly based turndown
flap, consisting of the dorsal surface of the nose and covered
with skin graft, has been established as useful surgical technique. The incision is carried through the scar contracture of
the dorsum of the nose, folded down toward the tip to create
an inferiorly based flap, and grafted with a split-thickness or
thin full-thickness skin graft [43].
Chapter 7. Treatment ofFacial Burns
193
Summary
The treatment of facial burn is one of the most challenging
aspects of burn surgery. Superficial burns are treated conservatively with antimicrobial agents. Full-thickness burns
require excision and skin grafting for the best outcome.
Indeterminate depth burns pose the most significant challenge. The timing and decision to excise the wound critically
impact facial scarring and the ultimate aesthetic outcome. If
a burn wound does not seem to heal in 2–3weeks, then excision and skin grafting should be considered. Scars and contractures have to be evaluated individually and the anatomical
regions considered carefully. Scar contractures are commonly
released with tissue rearrangement techniques in combination with ablative CO2 laser treatment.
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