If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Pediatric oral commissure burns present a therapeutic and reconstructive challenge. Although these injuries are fairly common in young children, there exists some controversy on the appropriate timing and nature of the repair that should be performed. Some authors advocate early surgical intervention, whereas others advocate a far more conservative approach that uses prolonged splinting techniques in the hope of avoiding the need for reconstructive surgery. In the event that reconstructive surgery becomes necessary, there exists a wide range of reconstructive techniques that are described in the literature, from simple excision and skin grafting to complex local flap reconstruction using adjacent or distant tissue. In this article, we present an overview of the nature of pediatric oral commissure burns, identify special concerns in pediatric burn patient, discuss the potential role for oral commissure splinting, and finally review a number of different surgical reconstructive techniques that have been proposed in the literature.
McCaig L, Nawar E: National Hospital Ambulatory Medical Care Survey: 2004 Emergency department summary. Advance Data From Vital and Health Statistics of the National Center for Health Statistics, 2006
Hing E, Cherry D, Woodwell D: National Ambulatory Medical Care Survey: 2004 Summary. Advance Data From Vital and Health Statistics of the National Center for Health Statistics, 2006
Up to 400,000 children are treated annually for burn injuries in the United States, and burns are the third most common cause of death among children aged 0-14 years.
Hall M, Owings M: Hospitalizations for injury: United States, 1996. NCHS—Vital and Health Statistics of the Centers for Disease Control and Prevention 218(4), 2000
It is important to keep in mind the possibility of nonaccidental injury in these cases, as up to 20% of pediatric burn admissions involve child abuse or neglect, particularly those cases involving scalding injuries.
It is noteworthy that boys are more commonly involved in burn cases than girls are, in some studies in a ratio as high as 2:1, and that children diagnosed with attention-deficit hyperactivity disorder also are at a higher risk.
Specifically, electrical burns tend to occur mostly in children aged between 0 and 4 years and tend to disproportionately involve the lips, mouth, or tongue.
In a series of all pediatric patients presenting with electrical burns, the mouth was the most common site of injury, nearly all patients were younger than 4 years (93%), and most patients were younger than 2 years at the time of injury (65%).
The most common mechanism of injury involves children biting into an electrical cord, touching the male ends of a live but improperly connected cord, or sucking on the female end of an extension cord that is plugged into the wall.
A contact burn, which is less common around the mouth, typically requires 2 points of contact, such that the current flows from the electrical source, pass through a part of the body, and exit through the ground via the path of least resistance. An arc burn, which is the most common type of injury around the mouth, results from the electrolyte-rich saliva completing a circuit between 2 conductive wires, which initiates an arc or a flash, and this has been reported to generate temperatures as high as 3,000°C. The low electrical resistance of the mucous membranes makes them particularly susceptible to severe injury via this mechanism. The most common site of involvement in the mouth is the oral commissure and the upper and lower lips adjacent to the commissure.
Although these injuries are rare, involvement of the oral commissure is common, and knowledge of the proper treatment is important to achieve acceptable functional and cosmetic outcomes.
Special concerns in pediatric burn patients
Caring for pediatric patients with facial burns requires a comprehensive and multidisciplinary approach to management, and the American College of Surgeons therefore recommends that all patients with facial burns be triaged to American Burn Association–certified burn centers.
When initially assessing pediatric facial burn patients, it is important to keep in mind the ABCs—airway, breathing, and circulation. Evaluation should be done for any physical evidence of airway burns, which can include charring of the mouth or lips, singeing of nasal hairs or eyebrows, dark and carbon-stained mucus, wheezing, changes in voice, difficulty in breathing, or coughing. In such cases, definitive airway management in the form of endotracheal intubation may be advisable given the possibility for airway edema that can develop in a delayed fashion after the injury. Particularly in children, it is important to keep in mind circulatory support. Major burn injuries are typically accompanied by massive fluid loss, and although children may initially compensate quite well for this, there exists a greater potential for precipitous and rapid circulatory collapse than what exists in adults. The Parkland formula and the palmar method allow for quick calculation of the amount of resuscitation fluid that is estimated to be required over the first 24 hours after injury. Verification of tetanus prophylaxis should be performed, and booster vaccinations can be administered if indicated.
Management of facial burns in pediatric patients is an area particularly fraught with psychological, developmental, functional, and esthetic concerns. The facial form contains various complex concave and convex surfaces arranged in juxtaposition, structures that are lacking in internal support, and multiple dynamic subunits that are responsible for sight, speech, and oral consumption. Therefore, treatment of these injuries requires a comprehensive, multidisciplinary approach that attends to the preservation of function and esthetics while also considering the psychological and developmental concerns unique to the pediatric population.
Oral commissure burns
There have been several classification systems put forth to describe the degree of tissue damage in pediatric patients with oral commissure burns; however, none has gained widespread acceptance. One schema created by Ortiz-Monasterio and Factor classified injuries according to the percentage involvement of the upper or the lower lip; however, a more recent classification system proposed by Al-Qattan et al
On initial presentation, burn injuries to the oral commissure typically appear gray to white with evidence of charring. The wounds are frequently painless and bloodless because of the nature of a high-temperature thermal injury. The lower lip and oral commissure are involved more frequently than the upper lip is, and patients may present initially with poor salivary control. Importantly, it is very difficult to assess the true margins of injury at initial presentation, and the actual area of involvement may be more than initially believed.
As the burn injury evolves, the patient begins to develop a rim of erythema and edema in the surrounding tissue, and after the first 24 hours, an obvious margin indicating the area of tissue necrosis usually forms because of thrombosis of the blood vessels in the affected area. Eschar and coagulative necrosis develop as the wound heals, with eventual slough of the eschar in 1-4 weeks. The developing scar has a tendency to contract as the soft tissue remodels over time. Although bleeding at initial presentation is uncommon, there appears to be a delayed risk of bleeding from the labial artery that can occur between 1 and 2 weeks following the injury in up to 25% of cases.
When treating facial burns, some authors outlined what they consider to be the 5 reconstructive goals of treatment: an undistracted, “normal” look at conversational distance; facial balance and symmetry; distinct esthetic units fused by inconspicuous scars; a doughy skin texture appropriate for corrective makeup; and a dynamic facial expression.
Although this pertains to all facial burns and is not specific to oral commissure burns per se, it does provide us with some important considerations to keep in mind when treating these injuries.
Treatment of oral commissure burns
The timing and the appropriate treatment for burn injuries to the oral commissure, lips, and tongue continues to be controversial. A wide variety of treatment strategies and surgical techniques performed at varying intervals from the time of injury have been studied and proposed without the development of any widespread consensus. In general and to more easily discuss the available treatment options, we can categorize interventions based on the time point at which they are performed: early intervention, which occurs within a few days of the injury; intermediate intervention, which occurs at the time that necrosis can be distinguished from normal tissue (typically 1-4 weeks); and delayed intervention, where repair is begun after all the tissues have healed (after several months).
The choice of treatment strategy can vary depending on the length of time elapsed since the burn injury, the degree and extent of the injury, and the individual surgeon׳s preferences.
Advocates of early intervention believe that the best results in treating oral commissure burns can be obtained with early excision of damaged tissue. These authors report that this approach results in faster healing, a shorter hospital stay, fewer total surgical procedures, and overall better final results. Some authors report promising results initially, whereas others report disappointing late functional and esthetic results.
It is also important to consider that early excision of damaged tissues can cause tightening of the soft tissue envelope over the mandible and subsequently impair bony mandibular growth and development.
A major disadvantage to this approach is that the extent of tissue damage and necrosis may not be initially evident, and attempts to estimate the area of involvement may result in resection of otherwise viable tissues.
Some authors prefer an intermediate course of intervention, favoring the excision of damaged tissue and eschar as soon as the extent of necrosis is clear and can be differentiated from the surrounding healthy tissues, typically 1-4 weeks after the initial injury. They report that this approach minimizes scarring, decreases the number of bleeding episodes from the labial artery by avoiding the inevitable slough of the eschar, avoids secondary infections as the wounds heal, and allows for better reconstructive results.
Advocates for conservative or delayed treatment point out that it can be difficult to assess the extent of injury immediately and that surgical intervention before scar maturation may increase the risk of hypertrophic scar formation.
They point out that after maturation of the scar, the extent of damage is more apparent, that functional and esthetic deficits would have more definitively declared themselves, and that reconstruction is ultimately more successful.
Authors variably advocate for the use of oral or topical antibiotic prophylaxis with or without vigorous scar massage with vitamin E or steroid-based creams.
The goal of splinting the oral commissure is to provide a countering force against the tendency for wound contracture, with the goal of reducing scarring, maintaining function, and reducing the need for reconstructive surgery. The use of oral commissure splints was described in the literature starting between 1972 and 1976.
There are many different devices that have been used for this purpose, including both intraoral and extraoral devices, as well as devices where the stretching force is applied vertically across the oral commissure, horizontally, or circumorally.
In general, use of the splinting device begins when most of the facial edema has resolved and patients are able to tolerate wearing the device with minimal discomfort. The splinting device is worn at all times, except for when the patient is eating or performing oral care. As the process of scar maturation and reorganization can continue for up to 1-2 years, the device is worn for a prolonged period of at least several months. Patient and parental compliance is crucial for success.
They found that before the introduction of routine splinting, 8 of 95 patients (8.4%) required surgery to correct microstomia, whereas after the introduction of routine splinting in 1974, only 3 of 85 patients (3.5%) required surgery. The authors found that of the 3 patients requiring surgery, 2 were noncompliant with the splint therapy, meaning only 1 patient of the 83 who underwent splinting ultimately required a surgical intervention for the correction of microstomia, which is a statistically significant difference (P < 0.03).
A second retrospective study examined 42 patients with oral commissure burns treated between 1968 and 1986 either with or without oral commissure splinting.
Of them, 20 underwent early splinting, whereas 22 did not undergo splinting therapy. They found that 7 of the patients who underwent splinting ultimately required surgical commissuroplasty, whereas 19 of the patients who did not undergo splinting ultimately required surgery (P < 0.05).
In addition, all 7 patients in the splinting group who ultimately required surgery wore their splints for less than 4 months, whereas the remaining 13 patients in the splinting group who did not require surgery wore their splints on average for more than 4 months, thus suggesting that for splinting to be effective, it must be performed for a prolonged period.
Taken together, the data, although limited and retrospective, do suggest that oral commissure splinting is a useful treatment for pediatric patients with oral commissure burns and may reduce the need for future surgical commissuroplasty.
The goal of oral commissure reconstruction should attempt to restore normal structures to their normal positions, and recreate a thin, mobile lip segment that moves dynamically and symmetrically with facial expression.
The treatment used to achieve these goals has changed significantly over the years. In the late 1920s, surgeons advocated for resection of the mature eschar followed by careful skin grafting to recreate the oral commissure. Unfortunately, this often failed to prevent the development of subsequent oral commissure contraction; hence, since that time, a number of other techniques have been advocated by a number of different authors.
Some surgeons have advocated the use of a lip mucosal advancement flap (Figure 1).
The way this technique was initially described, the scarring around the oral commissure is excised, and banner flaps using the existing vermilion are advanced into a lateral position that approximates the native position of the oral commissure. An advantage is that this technique, because the vermillion and the mucosa are being advanced, tends to give a more natural appearance than simple excision and skin grafting does.
A modification of this technique involves leaving all the scar tissue intact, and fashioning advancement flaps of existing vermilion that are advanced into a more lateral position (Figure 2).
Figure 1An example of a left-sided oral commissure injury (A). A lip mucosal advancement flap is performed by first excising the oral commissure scar (B) followed by advancement of the upper and lower lip mucosa into the defect.
Figure 2An example of a modification of the lip mucosal advancement flap closure. In this technique, the scarring at the oral commissure is left intact (A) and a recipient site is designed lateral to the existing commissure (B). Upper and lower lip mucosal flaps are then advanced into the defect lateral to the native oral commissure.
Using this technique, a new oral commissure is planned at a point 2 mm lateral to the native commissure to correct for expected postoperative scar contracture. An incision is then performed through the skin and muscle to completely the scarred tissue while preserving the native, undamaged mucosal tissue. Mucosal flaps from the cheek are then advanced along with the remaining vermilion to close the defect (Figure 3). The authors note that these cheek mucosal flaps tend to be more reliable and successful when compared with techniques in which only the vermilion is advanced into the defect; however, a downside to this technique is that it can also result in shortening of the oral aperture on the affected side.
Figure 3An example of cheek mucosal advancement flap reconstruction of an oral commissure defect (A). The existing oral commissure scar is excised (B) and a pedicled cheek mucosal flap is designed (C) and advanced into the defect (D) where it is sutured in place (E and F).
Using this technique, the oral commissure scar is partially excised, and buccal mucosa is advanced into the apex of the commissure (Figure 4). Split-thickness skin grafts are then taken from the adjacent lip tissue and are used to cover the existing raw surface of the injured vermilion. A full-thickness graft is then taken from the preauricular skin to reconstruct the skin immediately lateral to the oral commissure. This helps to blend the lateral aspect of the scar into the surrounding cheek. This technique has a number of distinct advantages. Firstly, the cosmetic deformity seen after oral commissure burns and reconstruction frequently extends onto the skin lateral to the oral commissure, an area that is not directly addressed with the use of vermilion or cheek advancement flaps.
In addition, simple advancement of the adjacent vermilion into the wound bed tends to result in a “bunching” effect that adds some bulk to the oral commissure and results in a poor cosmetic match at the mucocutaneous junction.
Figure 4An example of an alternative method of oral commissure reconstruction. The oral commissure scar is partially excised (A) and a buccal mucosal advancement flap is advanced into the apex of the commissure (B). Vermillion grafts are taken from the contralateral lip and used to reconstruct the upper and lower lip in the region of the oral commissure (C) followed by a full-thickness skin graft placed lateral to the commissure (D) to reconstruct the adjacent injured skin.
An advantage of using a tongue flap is that the flap can include muscle to replace missing orbicularis oris while also providing increased vascularity and durability. In addition, a large volume of tissue can be mobilized in this fashion to repair extensive defects that may not be amenable to closure with other techniques.
Although the cosmetic match between tongue tissue and the vermilion mucosa is not ideal, the authors believe it to be a better match than buccal mucosa.
The flap is designed as an anteriorly based tongue flap, taking care to exclude the filiform papillae present on the dorsal surface of the tongue. The donor site is closed primarily, and the tip of the tongue flap is advanced to the medial edge of the lower lip defect (Figure 5). The remainder of the flap is used to reconstruct the lateral lower lip, and the flap is typically divided at 2 weeks.
Figure 5An example of a pedicled ventral tongue flap used to reconstruct the oral commissure.
Oral commissure burns in the pediatric population remain a reconstructive challenge. In most circumstances, a delayed approach to repair is used, giving time for the initial wound to declare itself. The use of oral commissure splinting, although challenging in practice, has been demonstrated to help prevent the need for surgical reconstruction of the oral commissure in the future. If surgical reconstruction is necessary, the goals include maintaining both normal function and cosmesis. A number of different techniques have been advocated for reconstruction of the oral commissure, and each has particular advantages and drawbacks that may make it more or less well suited for a particular injury.
References
McCaig L, Nawar E: National Hospital Ambulatory Medical Care Survey: 2004 Emergency department summary. Advance Data From Vital and Health Statistics of the National Center for Health Statistics, 2006
Hing E, Cherry D, Woodwell D: National Ambulatory Medical Care Survey: 2004 Summary. Advance Data From Vital and Health Statistics of the National Center for Health Statistics, 2006
Hall M, Owings M: Hospitalizations for injury: United States, 1996. NCHS—Vital and Health Statistics of the Centers for Disease Control and Prevention 218(4), 2000
00072-X&id=gr1.jpg){kind=link}
00072-X&id=gr2.jpg){kind=link}
00072-X&id=gr3.jpg){kind=link}
00072-X&id=gr4.jpg){kind=link}
00072-X&id=gr5.jpg){kind=link}