A brief overview of acute management of facial burns, specific procedures regarding excision and different skin substitutes and dressings used for biological and definitive coverage.

1. Dr. Tauseef ul Hassan Resident Plastic Surgeon ACUTE CARE OF FACIAL BURNS

2. Initial Evaluation and Resuscitation Before management of the facial burn wound can begin, the patient should be properly and completely evaluated as these burns may be mostly associated with burns to other parts of the body as well. Often, this is a brief effort, particularly in patients with small, uncomplicated wounds. In those with larger burns, evaluation of the wound is often of secondary importance.

3. BURN PATIENTS SHOULD BE SYSTEMATICALLY EVALUATED USING ATLS.

4. PRIMARY SURVEY During primary survey, the emphasis is on support of the airway, gas exchange, and circulatory stability. Early recognition of impending airway compromise, followed by prompt intubation, can be lifesaving. Obtain appropriate vascular access and place monitoring devices. Complete a systematic trauma survey, including indicated radiographs and laboratory studies.

5. SECONDARY SURVEY Burn patients should then undergo a burn-specific secondary survey, which includes : A determination of the mechanism of injury. An evaluation for the presence or absence of inhalation injury and carbon monoxide intoxication. An examination for corneal burns. The consideration of the possibility of abuse, and a detailed assessment of the burn wound.

6. FLUID RESUSCITATION

7. Burn patients demonstrate a graded capillary leak, which increases with injury size, delay in initiation of resuscitation, and the presence of inhalation injury for the first 18-24 hours after injury. Because the changes are different in every patient, fluid resuscitation can only be loosely guided by formulas.

8. Most formulas recommend that all crystalloid be isotonic during the first 24 hours, generally Ringer lactate solution.

9. . The Brooke or Parkland formulas are reasonable consensus formulas and are used to help determine the initial volume of infusion. FLUID ESTIMATION FORMULAS

10. PARKLAND FORMULA 4 x weight of Patient x % TBSA burns = Volume (ml) Half of the total calculated 24-hour volume is administered in the first 8 hours post injury and the second half in the subsequent 16 hours.

11. LUND BROWDER CHART

12. RULE OF 9

13. Hand (Digits and Palm) of Patient represents 1% of TBSA

14. ADMISSION CRITERIA Any patient with intermediate and full thickness burns i.e.: 2nd or 3rd degree burns involving face should be admitted. An assessment of extent of burn and burn depth should be made.

15. BURN WOUND MANAGEMENT Divided into 4 general phases; (1) initial evaluation and resuscitation. (2) initial wound excision and biologic closure. (3) definitive wound closure. (4) rehabilitation and reconstruction

16. In common practice, still many patients with facial burns are allowed to heal spontaneously, often resulting in contraction and hypertrophic scarring. Such patients frequently present with recurring patterns of facial deformities which require late reconstructive surgery.

17. THE STANDARD NOWADAYS is more towards Initial Excision with grafting of facial burns.

18. FULL THICKNESS BURNS Whole of Dermis is destroyed

19. Debridement of loose blisters on admission. Scheduled for excision and grafting with 7-10 days.

20. INTERMEDIATE THICKNESS BURNS Damage to deeper parts of the Reticular Dermis

21. Re-hydration once or twice daily + Debridement + Topical Antibacterials like silver sulfadiazine. Re-Evaluation after 10 days to determine which areas won’t heal within 03 weeks. (90-95% of such wounds do heal within 03 weeks time).

22. Especially in adolescents and adults, the deep sweat and sebaceous glands of the central face make it likely that most second-degree burns will heal well with adequate topical wound care.

23. GOAL OF TREATMENT EXCISION AND GRAFTING OF THE FACE TO BE COMPLETED BY 21 DAYS AFTER INITIAL INJURY.

24. EXCISION GENERAL PRINICIPLES:

25. GENERAL PRINCIPLES Done under GA in Reverse Trendelenburg position.

26. Peri Operative antiboitics are administered. Endotracheal tube is wired to the teeth.

27. Those aesthetic units judged to be incapable of healing with 3 weeks are outlined with markers. Small unburned or healed areas must frequently be included in excision to preserve aesthetic units.

28. Excision must be deep enough to prevent the bed from healing underneath the graft which results in graft loss. (Excision should be deep enough to remove hair follicles). If burn is shallow, it is wise to excise shallowly or just scrap off any loose debris and apply allograft or xenograft. If this results in healing in 3 weeks, OK, otherwise return the patient to OT and resume planned procedures

29. SPECIFIC PRINCIPLES Different areas of face are approached methodically and differently in following order;

30. EYELIDS

31. These are excised first. Goulian Dermatome with 0.008” guard is used. Portions of orbicularisoris are frequently removed but rarely anything deeper. Bipolar cauterization is used for haemostasis.

32. MEDIAL CANTHAL REGION Most difficult if done with Gouline dermatome. Done piece-meal with size 15 blade. Bipolar cauterization is used for haemostasis

33. NOSE Gouline dermatome with 0.008” guard used. Upper Nose: Simple excision as it is well supported by the underlying bony framework. Nares: As little excision as possible should be carried out as it is better to Redo the graft than to remove significant live tissue. Bipolar cauterization and epinephrine soaked Tefil pads used for haemostasis

34. UPPER LIP Gouline dermatome with 0.008” guard used. Philtrum and Philtral columns are important so excision should be careful. Better to do Redo graft than to remove significant live tissue. Bipolar cauterization and epinephrine soaked Tefil pads for haemostasis.

35. LOWER LIP AND CHIN Gouline dermatome with 0.008” guard used. In areas of Mental prominence, excision should be minimal. Bipolar cauterization and epinephrine soaked Tefil pads for haemostasis.

36. EARS Not excised because of their complex 3-D structure. Spontaneous separation of eschar is allowed to occur followed by split thickness graft.

37. The most important point of early MX of deeply burned ears is prevention of auricular chondritis. This is a serious complication in which the cartilage becomes infected and quickly liquefies. Twice-daily cleansing and the application of topical mafenide acetate, which penetrates the eschar, can minimize the condition. Subsequent management of the ear is based on the depth of injury.

38. PERIPHERAL FACE AREAS These include four areas Right cheek Left cheek Forehead Neck Should be performed one at a time to prevent massive blood loss. Gouline dermatome with 0.01-0.02” guard used. Excsion should be done serially and not in a single setting as the areas involved are large. Bipolar cauterization and epinephrine soaked Tefil pads for haemostasis

39. GRAFTING SKIN SUBSTITUES AND MEMBRANES: These provide transient physiological wound closure. Provide a degree of protection from mechanical trauma, vapor transmission characteristics similar to skin, and a physical barrier to bacteria. Facilitate moist wound environment with low bacterial density. Mostly occlusive; therefore, they must be used with caution if wounds are not clearly clean and superficial.

40. HUMAN ALLOGRAFT Remains the optimal temporary skin cover. Vascularizes and provides durable temporary closure of wounds.

41. PORCINE XENOGRAFT Adheres to wound coagulum and provides excellent pain control.

42. AUTOLOGOUS EPITHELIAL CELLS SHEET Can be grown from full thickness skin biopsy specimen. Useful in patient with massive injury. Very fragile, expensive and provide unreliable definitive coverage.

43. ALLODERM Consists of cell free allogenic human dermis Requires an immediate thin epithelial autograft. Alloderm just prior to placement of a thin autograft

44. INTEGRA -R Provides scaffold for neodermis. Requires an immediate thin epithelial autograft.

45. Amniotic Membranes Amniotic Membranes dressings also provide good healing environments and do not need to be changed. Are easy to apply and are comfortable to the patient.

46. HYDROCOLLOID DRESSINGS Provide vapor and bacteria barrier while absorbing wound exudates. E.g; duderm, nuderm, tegaderm

47. IMPREGNATED GAUZES Provide vapor and bacteria barrier while allowing drainage. E.g. Mepitil, curafilhydrogel.

48. TRANSCYTE Synthetic bilamminate layer Inner Layer; populated with allogenic fibroblasts facilitates fibrovascular growth. Outer layer provides temporary vapor and bacteria cover.

49. BIOBRANE A synthetic Bilamminate layer.

50. ACTICOAT Non adherent wound dressing that provides low concentrations of silver for antispesis.

51. RE-EVALUATION AND AUTOGRAFTING After 1 week, patient is returned to operation theater for Re-evaluation and Autografting. Homografts are carefully inspected to see whether they are viable.

52. If homografts are well adherent to the wound surface and there are signs of revascularization, it means the area is ready for autograft. Reserve Full thickness donar skin with optimal color match is used as autograft for facial resurfacing. Upper back and shoulders make good facial donar sites.

53. When homografts are found to be loose and non adherent, facial wounds need to be excised and homografted again. IN this case, patient returns 4 days following the second stage for a further inspection. If homografts are well adherent, surgery proceeds for Fullthickness skin autografts.

54. The donar site should be the same as before for grafting to allow color matching. The grafts are then stitched into place with 4/0 or 5/0 plain catgut or vicrylrapide.

55. ROLE OF DERMABRASION In very young and very old individuals, the skin is not only thinner but has diminished hair-follicle and other adnexae density. This circumstance makes dermabrading second-degree-burn wounds more advantageous than other methods.

56. Careful removal of all damaged cells can be performed more precisely with dermabrasion than with the more conventional Weck knife or dermatome excision. Intact structures are not damaged, and a more reliable assessment of the burn’s healing potential and actual depth can be achieved early in the process.

57. The decision to add a skin graft or to cover it with a temporary skin replacement can be made, and the scar-enhancing inflammatory-response waiting period is eliminated.

58. THANK YOU!