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11.2 Minor Burns: Ambulatory Treatment
129
advantage of these agents over petrolatumimpregnated gauze (Heinrich et al. 1988;
Genuino et al. 2014). However, if the treating
physician wishes to use a topical antimicrobial
agent, there are several choices. The most popular is 1% silver sulfadiazine. In comparative
studies, it delayed spontaneous reepithelialization of partial- thickness burn wounds (due to its
silver component; Barret etal. 2000). However,
if the wound is covered with an eschar, 1% silver sulfadiazine has the fewest side effects and
is probably the best recommendation. It is not
used on patients allergic to sulfa products, pregnant women, nursing mothers, and infants less
than 2months of age (increases the possibility
of kernicterus). Bacitracin is an alternative topical prophylactic antibiotic. Several authors
favor its use because it is cheaper than silver
sulfadiazine. Alternatively, there has been
increasing interest in the use of combinations of
antibiotics in ointment (neomycin, bacitracin,
polymyxin B). They are effective against the
Gram-positive cocci and some of the aerobic
Gram-negative bacilli that most frequently colonize small burn wounds.
Infection can involve the depth and extent of a
burn converting a supercial dermal burn into a
deep dermal burn or even a full-thickness burn.
An infected burn is also more susceptible to sepsis. The appearance of gray or black spots, especially if there are other manifestations of
infection, should raise concern for invasive infection. Fortunately, it rarely occurs among those
treated as outpatients. However, when it occurs,
the patient should be admitted to a hospital. All
patients with a suspected burn infection should
therefore be managed aggressively as inpatients
with parenteral antibiotics. The view of a fullthickness skin biopsy of all infected burns to conrm the presence of infection and identify the
responsible microorganism has also been supported (Morgan etal. 2000; Hartford and Kealy
2007). Burns, even minor ones, are regarded as
tetanus-prone wounds (Larkin and Moylan 1975;
Solanki etal. 2014). Tetanus prophylaxis should
be provided, unless the patient has received tetanus immunization within 10 years (Rhee etal.
2005).
Covering burns serves a number of purposes.
Dressings provide anesthetic relief; they act as a
barrier against infection and keep the wound dry
by absorbing drainage. A wide variety of dressings exist, and the choice depends on the depth of
the burn. Non-medicinal white petrolatumimpregnated ne mesh or porous mesh gauze,
biologic dressings (allogenic amnion), and synthetic tissue-engineered dressings (Biobrane®,
hydrocolloid dressings, TransCyte®, other wound
dressings containing cultured autogenous keratinocytes with or without broblasts like Apligraf,
Integra, and AlloDerm) are readily available and
can be used for burn cover. Varkey etal. (2015) in
a recent review of covering materials suggested
that those containing supercial dermal broblasts (tissue-engineered skin with supercial
broblasts and keratinocytes) may prove benecial for postburn wound healing due to the antibrotic properties of the latter.
Supercial partial-thickness burns, the equivalent of sunburn, with intact epidermis, require
neither topical medication, nor a dressing.
Hartford and Kealy (2007) reported that most
burns of the face are treated without a dressing
for practical reasons. Many physicians prefer to
use a thin layer of bland ointment combined with
a topical antibiotic (e.g., Baciguent, bacitracin in
anhydrous lanolin, mineral oil, and white petrolatum), because it is more comfortable for the
patient and moist wounds heal more quickly than
dry wounds. Mabrouk etal. (2012) observed an
improvement in management and healing rate
and a better long-term outcome of partialthickness facial burns when treating those with a
moist occlusive dressing (Aquacel® Ag) compared to moist open dressing (MEBO®). Wasiak
etal. (2013) reviewed the literature regarding the
effects of burn wound dressings on supercial
and partial-thickness burns. Despite the poor
quality of trial reporting and trial conduct, the
authors concluded that burns treated with hydrogel dressings appear to heal more quickly than
those treated with usual care. Hoogewerf et al.
(2013a, b) conducted a literature search on the
effects of topical interventions on wound healing
in people with facial burns of any depth. Five randomized controlled trials were included. All stud-
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11 Burns oftheScalp, Face, andNeck
ies had small sample sizes and were at high risk
of bias. Heterogeneity of interventions and outcomes prevented pooling of data. In these studies, time to complete wound healing was
signicantly shorter for those using a skin substitute than for those using an antibacterial agent,
but the quality of evidence was low. Pain was signicantly reduced with the use of skin substitutes
in both studies that reported this outcome in all
groups (range mean difference– 2.00 to −4.80 on
a 10-point scale). They concluded that there is
insufcient high-quality research and evidence to
enable conclusions to be drawn on wound healing in patients with facial burns.
More recently, Slaviero etal. (2018) reviewed
the effect of various antiseptics and antiseptic
dressings on the healing of burn wounds and
reached similar conclusions to Hoogewerf etal.
(2013a, b), namely that at the present moment, it
is still uncertain whether the different products
used on burn wounds are associated with different healing rates. They, too, suggest that further
efforts are needed in order to provide stronger
evidence. Hoogewerf et al. (2020) reached the
same conclusion after a thorough literature search
on randomized controlled trials that evaluated the
effects of topical treatment for facial burns. Due
to low/very low certainty evidence, no differences could be established regarding wound
infections, pain, time to partial and complete
wound healing, adverse effects, length of hospital
stay, scar quality, and patient satisfaction between
the various used topical agents (Hoogewerf etal.
2020).
Recommendations regarding blister management are varied and range from leaving them
intact to removing the blistered skin immediately
or delaying removal. The author recommends
leaving blisters intact or, when indicated, decompressing the blisters, leaving the blistered skin to
protectively cover the wound. An intact blister
usually indicates a supercial dermal wound,
which will probably heal spontaneously within
3 weeks. If the blistered skin is removed, the
wound is converted from a painless one to a painful, open wound exposed to colonization by bacteria and potential infection (Hartford and Kealy
2007). A burn wound with an intact blister, how-
ever, rarely, if ever, gets infected. The uid will
be resorbed within the next 10–15days, and the
wound will heal spontaneously. If spontaneous
healing looks unlikely at follow-up, surgical
intervention to facilitate healing should be
undertaken.
Instructions regarding wound care, positioning, physical therapy, clinical signs of infection,
access to medical care, and pain medication are
given to the patient before release from the emergency room. Follow-up in 2–3days is mandatory
to check on the wound and the patient’s compliance with instructions. Further follow-up visits
are arranged accordingly. The objective in burn
care is to have all wounds healed within 1month.
In cases of a problematic spontaneous healing,
surgical removal of residual necrotic and granulation tissue by tangential excision and skin grafting is undertaken.
Most burn patients develop pruritus (itching),
an annoying and often unrelenting manifestation
of healing and healed burn wounds. A few studies
on this subject are methodologically robust. In
recent years, there has been an attempt to design
and implement treatment strategies and algorithms; however, there is currently no agreed and
consistent management plan for the treatment of
pruritus due to a burn injury. A variety of treatments are available for the relief of this annoying
symptom ranging from antihistamines (histamine
has been implicated in the genesis of itching) and
topical emollients to psychological therapies,
massage, and dermatological treatments. Oral
antihistamines are used most commonly, yet
research indicates that they are not always effective. The rst-line treatment should be simple;
however, if single therapies are unsuccessful,
combination therapy should be introduced early,
in order to reduce the onset of chronic itch
(Richardson etal. 2014).
Occasionally, patients with moderate or even
severe burns can be treated in the ambulatory setting. Lower cost, less chance of exposure to
antibiotic- resistant microorganisms, and a more
comfortable environment are the main advantages. However, the conditions that need to be
met in order to consider ambulatory care for any
patient include completion of intravenous resus-
11.3 Moderate andSevere Burns
131
citation; no ongoing complications; no wound or
systemic manifestation of sepsis; adequate nutrition established; and satisfactory pain control
(oral analgesics). Furthermore, wound care and
physical and/or occupational therapy need to be
arranged (Hartford and Kealy 2007).
11.3 Moderate andSevere Burns
Primary assessment of patients with moderate
and severe burns aims at quick identication and
treatment of life-threatening conditions. Exposure
to heated gases and smoke may result in damage
to the respiratory tract, formation of edema, and
airway obstruction. Progressive hoarseness is a
sign of impending obstruction. The latter may
develop rapidly following injury, and the respiratory status should be continually monitored, in
order to assess the need for airway control and
ventilator support. Initially, 100% humied oxygen should be given to all patients, when no obvious signs of respiratory distress are present. If
deemed necessary, an airway is established by
means of nasal endotracheal intubation. Early
intubation of patients with signicant burns,
inhalation injury, and facial/neck burns before
transfer has been emphasized (Table 11.2).
However, this has led to many potentially unnecessary intubations that expose patients to unnecessary complications. Although early intubation
is lifesaving for many burn patients, criteria
should be developed to determine when intubation is not needed (Romanowski et al. 2016).
After an airway is established, breathing must be
assessed in order to ensure an adequate chest
expansion. Assisted ventilation with 100% humied oxygen is required for all intubated patients.
Appropriate cervical spine stabilization must be
accomplished by, preferably, a cervical collar to
keep the head immobilized until the patient’s
condition can be evaluated.
The American Burn Association recommends
that if a patient is less than 60min from a hospital, an iv line is not essential and can be deferred
until a patient is at a hospital. If an iv line is
established, Ringer’s lactate solution should be
infused at 500mL/h in an adult and 250mL/h in
a child 5years of age or older. Children younger
than 5years need no iv lines (Mlcak and Buffalo
2007).
Prehospital care of wounds is basic and simple
because it requires only protection from the environment with application of a clean dressing to
cover the involved part. This is also the rst step
in diminishing pain. If there are further burn
wounds, the patient should be wrapped in a clean
sheet to minimize heat loss and to control temperature during transport.
The assessment of a burn patient in an A&E
department is essentially the same as outlined for
a prehospital phase of care. The primary care
begins with the ABCs, and the establishment of
an adequate airway is vital. Following the primary survey, a thorough head-to-toe evaluation
of the patient should be done.
Establishment of iv lines, preferably two
large-caliber iv catheters through unburned
areas, for uid resuscitation, is necessary for all
patients with major burns including those with
inhalation injury or other associated injuries
(Table 11.3). The lines are best placed in the
upper extremities peripherally. Ringer’s lactate
solution should be infused at 2–4 mL/kg/%
total body surface area (TBSA), which is
burned (ABA 2005). Children must have additional uid for maintenance (Herndon et al.
1993). The initial resuscitation should begin
with 5000 ml/m2/% TBSA burned/day
+2000 ml/m2/TBSA/day 5% dextrose in
Ringer’s lactate. This formula calls for one-half
of the total amount to be given in the rst 8h
post-injury with the remainder given over the
Table 11.3 Specic protocol for preparing burned
patients for medical evaluation
Cannulation of several venous routes of which one
should be central if possible (followed by chest
radiograph)
Monitoring of diuresis—Lactate, base decit, and
central venous saturation
Insertion of nasogastric tube
Sedation and/or analgesia
Cleansing of wounds
Tracheal intubation (if necessary)
Application of sanitary devices to prevent excessive
heat loss
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11 Burns oftheScalp, Face, andNeck
following 16h (Herndon etal. 1993). The uid
requirements in patients with an inhalation
injury have been studied, but largely in retrospective cohorts (Holley etal. 2020). The consensus opinion currently indicates an increased
uid demand in the presence of inhalation
injury compared to patients with the same percentage cutaneous burn but without inhalation
injury (Yeung etal. 2013). However, other studies have failed to demonstrate this increased
resuscitation uid requirement in patients with
an inhalation injury (Holley etal. 2020).
All resuscitation formulas are designed to
serve as a guide only. Adjustments according to
the individual patient’s response and needs ought
to be made. The best monitor of uid replacement is urine output. Acceptable hydration is
indicated by a urine output of more than 30mL/h
in an adult (0.5 mL/kg/h) and 1 mL/kg/h in a
child (Table11.3). Fagan etal. (2014) support the
notion that global parameters of perfusion (lactate, base decit, and central venous saturation)
are more appropriate than urine output alone in
reecting the degree and recovery from a hypoperfused state, or a state of shock. Inadequate
resuscitation can cause diminished perfusion of
renal and mesenteric vascular beds, whereas uid
overload can cause undesired pulmonary or cerebral edema. Decompression of the stomach with
a nasogastric tube is usually necessary (air,
diminished peristalsis due to pain medication/
narcotics).
Patients with facial burns occasionally have an
associated inhalation injury. In a recent retrospective study of 808 facial burns, the incidence
of inhalation injury was reported to be 3.06%
(Kalantar Motamedi et al. 2015). The classic
paper describing the effects of inhalation injury
on mortality in burn patients from the U.S.Army
Institute of Surgical Research in San Antonio,
Texas, reported a diagnosed inhalation injury in
373/1000 patients (ca 37%) (Shirani etal. 1987).
A decrease in the incidence of inhalation injury
(34% vs. 27% from 1996 to 2007) has been
observed in the Netherlands (Mackie etal. 2011),
whereas it is uncommon in other studies of burn
patients (1.9%, 5000 burns during a 7-year
period, Israel) (Haik etal. 2007).
Thermal airway injury is generally limited to
supraglottic structures, whereas injury to the
lower airway is chemical in nature. Toxic gases
(CO2, CO, HCN) exert their effects through
asphyxiation, systemic toxicity, or direct effects
on respiratory tissue (halogen acids, formaldehyde, etc.). The chemical injury stimulates vasomotor and sensory nerve endings to produce
neuropeptides, which can induce inammatory
response, increased vascular permeability and
vasodilation, bronchoconstriction, and nitric
oxide synthase (NOS) to generate reactive oxygen species (ROS) (Walker et al. 2015). These
factors potentiate local cellular damage and loss
of hypoxic pulmonary vasoconstriction, which in
turn causes increased bronchial blood ow. The
loss of an intact bronchial epithelium and the
effects of ROS result in a loss of plasma proteins
into the alveoli and bronchioles and cast formation within the airways, leading to alveolar collapse or complete occlusion of the airways
(Murakami and Traber 2003). The abovementioned processes contribute to ventilationperfusion mismatch as a primary mechanism of
hypoxemia following the smoke inhalation injury
(Walker et al. 2015). Respiratory failure may
occur 12–48h after smoke exposure. Because of
necrosis of respiratory epithelium, patients are
predisposed to secondary bacterial invasion and
superimposed bacterial pneumonia (Shirani etal.
1987). Tissue factor expressed by damaged respi-
ratory epithelial cells and alveolar macrophages
initiates the extrinsic coagulation cascade, disrupting pro- and anticoagulant alveolar homeostasis. Furthermore, smoke inhalation injury
contributes to a hypercoagulable state in the lung
by inducing plasminogen activator inhibitor 1
and stabilizing its mRNA (Middle etal. 2011).
Inhalation injury signicantly increases morbidity and mortality. It has been found to be an
independent factor of mortality in burn patients
and worsens survival even among patients with
similar age and burn size (Walker et al. 2015).
Physical ndings including facial injury, singed
nasal hairs, soot in the proximal airways, carbonaceous sputum production, and changes in voice
may help support the diagnosis (Dries and Endorf
2013). A recent study from Florida, however,
11.3 Moderate andSevere Burns
133
showed that singed nasal hair, carbonaceous sputum, and facial burns are unreliable evidence for
inhalation injury even in the context of an
enclosed space mechanism of injury (Ching etal.
2015). These ndings may be conrmed by diag-
nostic studies including ber-optic bronchoscopy
(FOB), typically performed within 24h of admission (Endorf and Gamelli 2007). Despite its limitations, FOB continues to be the standard
technique to assess the presence and severity of
inhalation injury. Its relative ease and availability
allow the initial diagnosis to be made and allow
the inhalation injury to be followed serially
(Walker et al. 2015). The use of scheduled
sequential bronchoscopy as a therapeutic tool
after inhalation injury showed several strong
trends towards less morbidity, fewer days of
mechanical ventilation, a shorter length of stay,
less antibiotic use, and shorter duration of treatment. These promising data should promote a
larger, multi-institutional trial in the future (Carr
and Crowley 2013). Other means of evaluating
the severity of inhalation injury include chest
CT. Problems with CT include determining the
optimal timing of the test and how to interpret
abnormal radiographic ndings in the setting of a
negative bronchoscopy (Walker et al. 2015).
Yamamura et al. (2013) reported that bronchial
wall thickness measured by using the chest CT
scans obtained within a few hours of admission
was predictive of the total number of ventilator
days, ICU-stay days, and development of pneumonia in patients with smoke inhalation injury.
Thermal injury to the upper airway may cause, as
mentioned previously, massive swelling of the
tongue, epiglottis, and aryepiglottic folds with
obstruction. Some physicians support early intubation (Palmieri 2007). However, airway edema
develops over a matter of hours as uid resuscitation is ongoing. Initial evaluation is not a good
indicator of the severity of obstruction that may
occur later (McCall and Cahill 2005). Respiratory
status should be continuously monitored in order
to assess the need for airway control and the indication for intubation to protect the airway (Dries
and Endorf 2013). Targeted therapies for inhalation injury are limited. Supportive respiratory
care (pulmonary toilet, mechanical ventilation
when indicated) is one of the fundamental tenets
(Walker et al. 2015). Bronchial hygiene (early
ambulation, chest physiotherapy, airway suctioning, and therapeutic bronchoscopy) is paramount
in patients with inhalation injury. There is no
ideal respiratory support strategy. Many studies
support benet with noninvasive ventilation due
to the avoidance of endotracheal intubation and
its associated complications. Reduction in incidence, cost impact, and subsequent mortality of
pneumonia is particularly discussed as an advantage of noninvasive ventilation. The most serious
complication of the latter is failure to recognize
when this therapy is not providing adequate ventilation oxygenation or airway support resulting
in deterioration of the patient (Endorf and Dries
2010). Consensus recommendations for mechan-
ical ventilation continue to serve as general
guidelines (Mlcak etal. 2007). Ventilator strategies must support oxygenation and ventilation
and reect the experience of the clinicians managing the patient. Limitation of pressure, acceptance of permissive hypercapnia, and strategies to
manage secretions are important (Dries and
Endorf 2013).
A number of ventilation modes have been recommended for the patient with inhalation injury.
High-frequency percussive ventilation (HFPV)
has been shown to increase the Pa O2/Fi O2 (arterial partial pressure of oxygen/fraction of inspired
oxygen) ratio (Walker etal. 2015). A recent systematic review concluded that high-frequency
percussive ventilation may decrease in-hospital
mortality and pneumonia incidence when compared to standard controlled mechanical ventilation. However, the authors conceded that the
absence of “good-quality” evidence precluded
performing a meta-analysis (Miller etal. 2018).
Airway pressure release ventilation (Dries and
Marini 2009) and high tidal volume ventilation
(Sousse etal. 2015) have been shown to be benecial for patients with inhalation injury.
Treatment of carbon monoxide (CO) poisoning involves providing 100% oxygen, which
shortens the half-life of carboxyhemoglobin
(COHb) to about 45 min. Hyperbaric oxygen
therapy (HBO) has been used and can further
reduce the COHb half-life to about 20 min. A
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11 Burns oftheScalp, Face, andNeck
systematic review found that there is not enough
evidence to determine denitively whether HBO
reduces adverse neurologic outcomes after CO
poisoning (Buckley et al. 2011).
Hydroxycobalamin is the antidote of rst resort
in cyanide exposure. It binds to hydrogen cyanide
(HCN) to form cyanocobalamin, which is nontoxic and excreted in the urine (Walker et al.
2015).
Supportive clinical treatment involves the use
of medical adjuncts like bronchodilators (B2adrenergic agonists such as albuterol and salbutamol or nebulized epinephrine), mucolytic agents
(N-acetylcysteine), anticoagulants (heparin, heparinoids, antithrombin, and brinolytics), and
anti-inammatory agents, which have been used
primarily in animal models (Dries and Endorf
2013; Holley etal. 2020).
The most common complication following
inhalation injury is respiratory tract infection and
more specically pneumonia. Whereas mortality
with burns and concomitant inhalation injury was
reported to increase by 20%, it increased to 60%
with the development of pneumonia. Delayed
complications of intubation or complications
associated with tracheostomy, long-term tracheal
stenosis, vocal cord problems, and bronchiectasis
are also encountered after inhalation injury.
Long-term follow-up is necessary in order to
identify and monitor the development of these
complications (Walker etal. 2015; Holley etal.
2020; Charles etal. 2021).
11.4 Surgical Wound Care
Most burns go on to heal spontaneously and do
not require operation. Their treatment is directed
towards promoting healing, and a wide variety of
dressings are currently available. Dressing selection should be based on their healing effects;
however, ease of application and removal, dressing change requirements, cost, and patient comfort should also be considered. According to a
recent study, which reviewed all randomized controlled trials evaluating the effects of burn wound
dressings on the healing of supercial and partialthickness burns, there is a paucity of high-quality
evidence regarding their effect (Wasiak et al.
2013). Silver sulfadiazine was consistently asso-
ciated with poorer healing outcomes than biosynthetic, silicon-coated, and silver dressings, while
hydrogel-treated burns had better healing outcomes than those treated with usual care (Wasiak
etal. 2013).
Some burns are indeterminate or of mixed
depth. Some of these may require debridement
and/or escharotomy and ultimately skin grafting
of a portion of the wound, but that is not obvious
on presentation. Demarcation of the areas which
need tangential excision of the formed eschar
(3–4 days post-incident) and skin grafting will
aid surgical treatment of the burned face.
Full-thickness facial burns which need grafting are less problematic. The operative procedure
can be scheduled as soon as facial edema has
subsided. Face masks are used in some centers in
order to exert pressure so that the grafts can be
applied to a more normal surface. Tangential
excision of the eschars can be a very bloody operation. The use of epinephrine is indicated; furthermore, excision with needle-point
electrocautery works well. If there is any doubt
regarding depth, tangential excision with a
Goulian knife is more appropriate as preservation
of any viable dermal elements is essential for
optimum results (Muller etal. 2007). Temporary
wound closure with allografts is a good option if
one decides to delay the reconstructive phase in
order to decrease graft loss due to hematoma
formation.
Selection of site and depth of donor skin harvest needs careful consideration. Color match is
important; therefore, skin grafts from the “blush”
area above the line of the nipples should be used
whenever possible.
Respecting the aesthetic units of the face gives
better results, and grafts should be placed accordingly. Fibrin glue is often used in some centers in
order to increase graft adherence limiting hematoma formation. In cases where not the whole
aesthetic unit is involved, the question arises as to
what to do with unburned areas. It is not customary to excise and graft the whole unit in order to
achieve a better aesthetic outcome (Muller etal.
2007).
11.4 Surgical Wound Care
135
Fraulin etal. (1996) conducted a comparative
study in order to assess the cosmetic and functional results of conservative versus surgical management of facial burns. Forty patients were
categorized in four groups according to the depth
and management of their burns: (A) healed without surgery in less than 21days, (B) healed without surgery in 21 days or more, (C) early
debridement and thick split-thickness skin graft
(STSG) in 18days or less after the burn, and (D)
delayed debridement and thick STSG in more than
18days after the burn. Group A patients had a signicantly better overall rating on the scar assessment scale than the patients in the other groups
that required more than 21days to heal, B, C, and
D.Also, skin-grafted areas in the surgically treated
groups C and D had a signicantly better scar rating than wounds that healed spontaneously in
group B. There was no signicant difference
among groups B, C, and D when the total number
of persistent functional problems after treatment
was compared. The most common functional
problems for these patients were microstomia and
eyelid ectropion (Fraulin etal. 1996).
Philp etal. (2012) assessed the late outcomes
after grafting 35 patients with full-thickness
facial burns. Fourteen patients were available for
late (40±33months, range 5–91months) follow up. The most problematic late outcomes that the
authors identied 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 of different methods of
facial grafting in 160 children with facial burns
were assessed by Greenhalgh et al. (2013). In
addition, the authors determined the efcacy of
using allograft skin or Integra as temporary covers. Allograft and Integra were used for massive
burns. Of these, 39% died, 17% developed an
Integra infection, and 43% required regrafting
before autografting. The authors concluded that
when there is a shortage of autograft, allograft or
Integra is a good option, but Integra does not
reduce the need for reconstructive surgery.
Occasionally, deep facial burns result in broproliferative scarring, skin contractures, or
chronic wounds that take weeks or months to
heal (Hall etal. 2017). This in turn leads to disgurement and functional impairment constituting a
major therapeutic challenge. Postburn treatment
of these deformities is possible with Z-plasties,
new skin grafts, pre-expanded local aps, preexpanded prefabricated locoregional aps, and
free and perforator aps (Spence 2008; Li etal.
2009; Zan et al. 2013; Lazzeri et al. 2013)
(Fig. 11.12). Partial unit to subtotal/total face
deformities can be satisfactorily resurfaced,
occasionally in combination with full-thickness
skin grafts (especially for the central portion of
the face, Spence 2008). Complications associated
with the tissue expander have been reported in
18% of patients and signicant ap loss in 5%
(Spence 2008). Free and perforator aps (e.g.,
the anterolateral thigh ap, the thoracodorsal
artery perforator ap) provide good functional
and aesthetic results especially for reconstruction
of severe postburn neck contractures with a low
Fig. 11.12 (a–c) Forty
ve-year old patient
with full thickness
(deep) burn of the
posterior scalp. The
burned tissue has been
excised and replaced
with a free latissimus
dorsi muscular ap
covered with split
thickness skin grafts
abc
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11 Burns oftheScalp, Face, andNeck
necessity for secondary procedures and low
donor-site morbidity (Yang et al. 2002; Mun
etal. 2007). Some regional perforator aps (anterior supraclavicular artery perforator ap) can be
used either as pedicled or as free aps (Pallua and
Wolter 2013). In highly selected cases of severe
panfacial burns, facial vascularized composite
tissue allotransplantation is a realistic option
which can be considered, especially in cases of
devastating electrical facial injuries. However,
determining whether the patient is a candidate for
face transplantation is crucial, in order to avoid a
series of unwanted sequelae (Janis et al. 2015;
Bharadia etal. 2017).
Specic problems encountered in cases of
burns of the various facial units will be highlighted in the following sections.
11.5 Perioral Burns
Acute reconstructive surgery is carried out during
the rst months after burn injury and aims at
facilitating patient care or at preventing acute
contractures from causing permanent secondary
damage. Acute reconstructive intervention is
most frequently indicated in cases of perioral,
eyelid, or cervical burns.
Partial- and/or full-thickness perioral facial
burns may lead to a contracture of the tissues surrounding the oral commissures resulting in
microstomia (Fig. 11.13). The latter negatively
affects speech, eating, dental hygiene, expression, social interaction, psychosocial well-being,
and, when necessary, administration of general
anesthesia. Orofacial contracture management
combining exercise and stretching which was initiated within 48 h of admission and continued
until functional goals were consistently achieved
was shown to have positive outcomes for patients
with partial-thickness orofacial burns. Some
functional loss, however, remained with patients
demonstrating persistent reduced vertical mouth
opening at conclusion of treatment compared to
their healthy counterparts (Clayton etal. 2015a).
Nonsurgical exercise after full-thickness burns
can result in positive gains; however, the duration
of rehabilitation is considerable (eventually longer than 2years) and some degree of long-term
loss in functional mouth opening remains
(Clayton etal. 2015b).
Mouth splints are widely utilized at burn centers and by medical professionals for the prevention of oral microstomia. These devices may be
obtained commercially or are custom made by
hospitals’ therapists. Mouth splints may be fabricated static or dynamic for the horizontal or vertical opening of the mouth (Taylor and Walker
1997; Dougherty and Warden 2003). The use of
stacked tongue depressors is a simple acceptable
technique to aid in reversing oral microstomia. In
cases of microstomia, the vermilion becomes
scaled, cracked, and inelastic, increasing the
retraction of the commissures. The main objective of surgical treatment is to obtain sufcient
mouth opening, while maintaining the function
of the orbicularis oris muscle, and to secure normal function (eating, talking, oral hygiene). The
Z-plasty and the V-Y plasty are powerful tools in
the surgeon’s armamentarium for facial burn
reconstruction. They lengthen linear scars by
recruiting lax-adjacent lateral tissue (Ivy 1971).
abc
Fig. 11.13 (a–c) Twenty eight-year old male patient with perioral burns. The microstomia is clearly noticeable
(Courtesy: Prof. DAM McGrouther, Consultant P/R Surgeon, Phoenix Professor of Plastic Surgery)
11. 6 E yelids
137
Z-plasty can also cause a profound benecial
inuence on the physiology of scar tissue through
the immediate and continuing breakdown of collagen, which occurs in hypertrophic burn scars,
which occurs following the relief of tension
(Longacre et al. 1976). Z-plasty also narrows a
scar at the same time that it lengthens it. The
improvement in the appearance and functionality
of the mouth area following a Z-plasty can be
dramatic (Grishkevich 2011), particularly when
combined with pulsed-dye laser treatment. Free
skin grafts used after opening the commissures
will retract, unless the graft is kept distended for
a long period of time. This can be achieved with
appropriately shaped wires, which are buried
under the borders of the wound after excision of
the scar tissue. Full-thickness skin grafts can then
be sutured in place. The wires are removed in
3–4 months (Planas et al. 1999). Mucosal V-Y
advancement aps and rhomboid trapezoid
mucosal aps have been used with success after
scar excision for the reconstruction of the oral
commissures. Acceptable aesthetic results and a
good functional outcome were achieved with
only minor wound-healing disturbances and no
complications (Zweifel etal. 2010; Grishkevich
2011). Reconstruction of the philtrum, when
indicated, is best performed by the technique of
Schmid (1964) using a composite graft from the
triangular fossa of the ear. Local skin aps (the
nasolabial ap) have been used by other authors.
Favorable results were achieved with no postoperative use of a splint (Makiguchi etal. 2014).
Expanded skin aps have also been used for the
reconstruction of perioral burn deformities.
Sakurai et al. (2007) reported the use of an
expanded frontal scalp ap with which postburn
lip deformities were reconstructed. The result
was aesthetically and functionally successful.
In cases of severe cicatricial microstomia and
associated facial/neck scarring, a free perforator
ap has been utilized. Jin etal. (2009) reported
favorable experience with the deep inferior epigastric perforator (DIEP) ap, which is suitable
for the repair of massive defects of the face and
neck due to its size (especially when used as a
bipedicled ap), has reliable blood perfusion,
provides soft and pliable tissue, and causes mini-
mal donor-site morbidity. Smaller lower lip and
chin burn deformities can be satisfactorily reconstructed with a free radial forearm ap. Lee etal.
(2006) reported favorable results with the latter
ap in seven patients with hypertrophic burn scar
contractures of the lower face. In order to achieve
a better outcome, the authors limited the ap to at
least one nger breadth above the hyoid bone
because its low setting may deteriorate the cervicomental angle. Furthermore, they attached the
ap dermis to the wound bed for reconstruction
of the labiomental sulcus.
Macrostomia is caused by rapid contraction of
open wounds or grafts in the perioral region and
cheek. This contraction results in eversion of the
upper and lower lips and lateral movements of
the oral commissures widening the mouth opening. Drooling and desiccation of the oral mucosa,
which can lead to irreversible damage to the dentition, are the result of macrostomia. Early intervention with release and grafting of the lower
and/or upper lip is indicated, whereas denitive
reconstruction is best carried out at a later period
(Donelan 2007).
11.6 Eyelids
Facial burns might well be associated with signicant ocular trauma, dened as globe or eyelid
pathology. In a series of 865 patients admitted to
Temple University Health Sciences Burn Center,
127 (15%) presented with burn injuries to the
globe and/or eyelids (Stern etal. 1996). In another
series of 189 patients with facial burns referred
for consultation by an ophthalmologist, 143/189
had burn injuries of the eyes or lids that required
care. Lid involvement was encountered in
122/189 (78 bilateral, 44 unilateral). In 61 cases,
thermal or chemical burns to the conjunctiva or
lens were present (Still Jr etal. 1995).
The most important clinical recommendation
is to rinse a thermally or chemically burnt eye as
soon and as extensively as possible. Any delay
worsens prognosis (Schrage etal. 2011). This is
often only achievable when ordinary tap water is
being used (Claassen etal. 2021). For chemical
eye burns, the most efcacious decontamination
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11 Burns oftheScalp, Face, andNeck
solution is currently uncertain. For some other
proposed alternatives to water, such as the
Diphoterine® solution, there is growing evidence
of possible superiority in the duration and outcome of the healing process and in the treatment
of pain (Wiesner etal. 2019). Early ophthalmological review and prophylactic ocular lubrication are mandatory in burns involving the eyelids
(Mustardé 1991; Malhotra etal. 2009). The use
of prophylactic ocular surface lubrication may
provide early corneal protection, thereby minimizing ulceration in patients who may otherwise
have required surgery, especially in those with
mild-to-moderate exposure. In a series of 66
patients with facial burns involving the lids or
eyes, 18.4% of those treated with lubrication
required ocular surgery as opposed to 30% when
prophylaxis was not used (Spencer etal. 2002). It
is difcult to accurately assess initially the severity of burns of the eyelids, unless they are coagulated or charred. Initial debridement is therefore
not indicated. All burns of the lids should be
treated, primarily, with antibiotic drops or ointment into the conjunctival sac every 4h, plus a
mydriatic when the cornea has been damaged
(Mustardé 1991). When necessary, further corneal damage due to exposure may be prevented
by creating a “moist chamber” over the affected
eye (plastic watch glass on a ring of twisted fatty
gauze built up on the periorbital area). As soon as
the sloughs separate, split skin grafts should be
applied to the granulating areas to provide skin
cover. Further grafting will be required once the
phase of contraction has passed.
Burns to the periorbital region can cause upper
and lower lid ectropion (intrinsic contracture),
which can also arise secondarily due to contracture of open wounds and/or skin grafts at distant
sites (extrinsic contracture). If eyelid retraction
(ectropion) causing corneal exposure occurs,
early surgical intervention often requiring repeat
procedures is indicated (Malhotra et al. 2009).
Permanent visual impairment is rare with such
prompt management. No standard rules exist
regarding the tissue used for eyelid reconstruction. Each case requires an individual approach
based on the available skin (Malhotra etal. 2009).
Release of the contracture and resurfacing of the
area with split-thickness skin grafts are considered effective methods to restore protective eyelid function (Mustardé 1991; Donelan 2007). A
medium-thickness split skin graft should be used
for the upper eyelid, which will give the suppleness which is required to permit rapid blinking.
Because the thinner skin will contract more,
about twice as large a graft (in a vertical direction) is used as will eventually be required. In the
lower eyelid, a full-thickness skin graft from
behind the ear should be used. This will contract
less than split skin grafts and overlying the tarsus
it offers no obstruction to movement, despite the
fact that it is a rather thick graft (Mustardé 1991).
A tarsorrhaphy is totally unnecessary and may
cause damage to the lid margin (Mustardé 1991,
Donelan 2007). In severe burns, the underlying
brosis may cause more contraction than was
rst anticipated. Therefore, a second and sometimes a third graft may be required, each on the
marginal side of the last (Mustardé 1991). During
overlying scar release, care ought to be taken to
prevent damage to the underlying orbicularis
oculi which is often rolled up and contracted. It
must be unfolded to its normal at broad shape
before skin grafting. However, in cases of deep
burns with destruction of the underlying orbicularis oculi muscle, the freeing of deeper tissue is
more cumbersome and much scarred muscle may
require to be excised. Repeated excisions and
grafting may lead to a rather stiff lid, which in the
case of the lower lid is of no great importance. In
the case of the upper lid, however, the lid must be
long enough to allow the cornea to roll under it
during sleep and be completely covered. The disability of such a lid xation is overcome by
retracting the head, rolling the eyes down, and
looking out from below the xed lid, provided
that there is a gap of some sort between the lids
(Mustardé 1991).
It has been reported that 50% of eyelid burns
are partial-thickness burns which heal spontaneously in 1week, whereas 12% are full-thickness
burns that require release and grafting (Frank
etal. 1983). Early release within 7days of burn
and grafting was reported to prevent the development of exposure keratitis, progressive conjunctivitis, and corneal ulceration and should be
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