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Address reprint requests and correspondence: Gregory R. Dion, MD, Dental and Craniofacial Trauma Research Department, U.S. Army Institute of Surgical Research, 3698 Chambers Pass, Bldg 3611, JBSA Fort Sam Houston, San Antonio, TX 78234-7313.
Department of Otolaryngology, San Antonio Military Medical Center, JBSA Fort Sam Houston, TexasDental and Craniofacial Trauma Research Department, U.S. Army Institute of Surgical Research, San Antonio, Texas
Burns of the face and neck are devastating injuries with significant psychological and functional morbidity. A detailed understanding of the severity of head and neck burns is key to effective acute management of these injuries and prevention of long-term complications. This article focuses on acute management of burns of the face and skin both in the inpatient setting and managing the sequelae of facial burns including hypertrophic scarring, contractures, and functional issues such as microstomia and ectropion.
Though the mortality associated with burns has decreased in recent decades due to advances in intensive burn management, burns still cause significant morbidity.
Burns to the face and neck are particularly devastating injuries and can cause both profound functional and psychological morbidity. The incidence of facial burns varies widely in the literature from 6% to 60% of all burns
Burns are defined by depth of soft tissue injury and the total body surface area (TBSA) that is affected. TBSA is estimated clinically and is important for determining fluid resuscitation and nutrition requirements in burn patients. A common method of estimating TBSA is the Wallace Rule of Nines.
This tool assigns percentages of body surface area to different parts of the body. The head and neck account for a total of 9% of TBSA in adults, with 4.5% assigned to the anterior face and neck and 4.5% assigned to the scalp and posterior neck.
Burn depth is essential in classifying the severity of burn injuries and guides treatment in most cases. Depth is generally classified into 4 categories based on the tissue layers that have been damaged (Figure 2). Superficial burns are characterized by damage to the epidermis with clinical presentation notable for pain and erythema of the affected area. The epidermis regenerates over a period of a few days, and there is no substantial scarring appreciated. Superficial partial thickness burns extend down into the papillary dermis and cause pain, erythema, and blistering of the skin. Capillary refill remains intact and the skin re-epithelializes in 7-21 days with a likely return to full function of the burned tissue. Deep partial thickness burns extend to the reticular dermis, destroying blood vessels, nerves, and adnexal structures of the affected areas. As a result, there is no capillary refill and the skin is insensate. The skin is a pale color and may appear blistered. The skin may re-epithelialize over 21-60 days without intervention, but the risk of scar and decreased function of the tissue is common. Full thickness burns involve the layers deep to the skin including subcutaneous fat, muscle, or bone. These burns are insensate and have a leathery or gray appearance and generally do not blister. These burns do not have potential for regeneration because all of the adnexal structures are destroyed and are likely to have functional limitations and extensive scarring.
In a 15-year retrospective review of 205 patients with facial burns admitted to a burn center, 80% of burns were superficial partial thickness, 12% were deep partial thickness, and 6% were full thickness injuries.
Burn depth is often assessed clinically, but this is an imperfect mechanism that may evolve over the course of the first few days. Many other methods for assessing burn depth have been investigated including thermal imaging and laser Doppler imaging, but these techniques all have limitations in terms of accuracy and required equipment. As result, simple clinical assessment remains the most common tools for estimating burn depth.
Initial management of burns to the face and neck revolves around airway stabilization because of the risks of upper airway edema and smoke inhalation injury.
The assessment for intubation is important in the initial evaluation both in the field and on arrival to the emergency room or burn center. A retrospective review recently examined the airway management of 284 patients with facial and neck burns. They found that 38% of these patients arrived at the burn center intubated, with 75% of the intubations occurring in field and the other 25% in ED for concern of inhalation injury. Of these patients who arrive intubated, however, only 23% had confirmed airway burns on bronchoscopy.
Often the intubations in the field were performed for indications of soot in the oropharynx or nasopharynx or singed nasal hairs, which may not be good predictors of true airway edema.
Other retrospective data suggest that isolated physical exam findings of singed nasal hairs, carbonaceous sputum, and facial burns are poor predictors of smoke inhalation injury.
Though there are not strict intubation guidelines in the burn setting, several burn centers use criteria that include: respiratory failure, >20% TBSA burns for pain control, partial of full thickness burns involving the entire face and neck, and symptoms of laryngeal edema like stridor or hoarse voice.
It is important to note that care must be taken to secure the endotracheal tube in a way to minimize pressure on burned tissue in the case of facial burns.
This may include frequent adjustment of strap or attempting to minimize pressure on burned tissue.
Treatment
Topical Treatments and Debridement
After the airway evaluation has been completed, the initial treatment of face and neck burns involves local wound care with gentle debridement and topical antibiotics.
Given that the clinical assessment of burn depth may evolve over the first several days after injury, the decision for further surgical management is deferred until the wound has declared itself.
Bacitracin is a widely used antibiotic ointment in facial burns and ophthalmic bacitracin is required for periorbital burns. Ointment is removed and reapplied at least daily, and the removal of ointment provides a gentle debridement of the injured skin.
For deep partial thickness and full thickness burns, 1% silver sulfadiazine is an antimicrobial that is often used to prevent wound desiccation. The use of silver sulfadiazine is somewhat controversial with some centers
arguing for its routine use in areas like the ears to prevent chondritis, while other centers avoid the medication on the face completely because they believe it inhibits re-epithelialization.
Conservative management of facial and neck burns is continued for 5-10 days while the patient is systemically stabilized. The need and timing of surgical intervention is variable between institutions, but approximately 10%-20% of all patients with head and neck burns will require surgical intervention.
Excision can be difficult because of the complex contours of the face, and there are many methods employed to achieve adequate and even excision of tissue. Sharp excision using a flat goulian knife is a classic method for flat surfaces of the head and neck with scalpel and sharp scissors used for tighter areas. Hydrodebridement using tools such as the VersaJet hydrosurgery system are effect on concave and areas and complex 3-dimensional structures like the ears and nose.
The VersaJet system (Figure 3) uses a stream of sterile saline under high pressure to perform precise tangential debridement, and there have been several studies that have found this tool to be extremely effective for use in the head and neck.
Grafting is then performed over the debrided areas with either allograft or autograft materials. The most common donor sites for autografting of the face are scalp, neck, supraclavicular regions, and inner arms or thighs.
Generally split thickness skin grafting is used for the face and neck, with the exception of the upper and lower eyelids, which require full thickness skin grafts. Preferred donor sites for full thickness skin grafts for the eyelid skin are the inner arms as they provide a comparable match in skin thickness. Allograft materials such as Integra or Alloderm may also be used for partial or full thickness injuries. These allograft options are biosynthetic dressings that provide a scaffold for the formation of new dermis. The decision of whether to used autograft or allograft materials depends in part on the TBSA of burns and whether there is sufficient donor graft material available.
Many centers will elect to perform allografting at the time of initial excision and will reserve skin grafting for areas that have not healed when the allograft materials are removed.
Though it is widely accepted that full thickness burns typically require surgical intervention, there is significant debate regarding the management and timing of surgery for superficial and deep partial thickness burns. Some centers favor conservative management of partial thickness burns for up 14-21 days in order to allow superficial burns to heal and minimize the amount of tissue that will require excision and grafting.
Others recommend early excision and grafting for partial thickness burns at 6-10 days to reduce the risk of hypertrophic scarring which can cause long-term complications of scar contracture and decreased function.
Those who favor early excision also argue that this method decreases the risk of local wound infection. There is no high-quality evidence to guide the decision on timing of surgery.
This allows time for burn scar to fully mature and the effects of the previous interventions to be appreciated. An exception to this rule is the eyelid, which may be grafted earlier than 6 months after injury because of the importance of protecting the eye. Management of secondary reconstruction centers around improving function and appearance of burned areas and may involve scar contracture release, further skin grafting, and even free flap reconstruction of large burned areas.
Complications
The goal in acute and long-term management of head and neck burns is to minimize complications that can affect not only a patient's functional status but also their psychological health. Hypertrophic scarring and wound contracture are the main long-term complications following head and neck burns and can affect all the functional structures in the area including the ears, nose, mouth, and eyes. The following discussions will discuss some of the most frequent and debilitating complications of head and neck burns.
Neck Contracture
Neck contracture is a frequent and potentially debilitating complication of neck burns (Figure 4). Contracture and hypertrophic scarring can cause decreased range of motion of the neck and head as well as difficulty swallowing and function of the lower portion of the face.
Neck contracture is in part related to positioning during the initial inpatient stay. Patients who are intubated or undergo tracheostomy during their admission are significantly more likely to have neck contracture because of limitations in movement required by the advanced airway management. Additionally, patients with upper extremity burns are more prone to neck contracture because their arms are kept in abduction to preserve shoulder range of motion. This shortens the neck and can lead to scarring.
In the acute setting, positioning the neck in hyperextension and performing frequent neck range of motion exercises with physical therapy decreases the likelihood of neck contracture.
Patients with long-term contracture and decreased range of motion not improved with physical therapy often require delayed reconstruction with scar release with the option for skin grafting, local flap, or regional/free flap reconstruction depending on the area of the contracted skin.
Orofacial contracture resulting in microstomia is a risk in perioral burns (Figure 5). This can cause significant functional and cosmetic morbidity including dysphagia, poor articulation, poor mouth opening for intubation, oral incompetence, and distorted expression.
Preventing this complication begins on initial admission to the burn unit and may involve physical therapy and splinting. A prospective cohort study of 229 patients undergoing comprehensive orofacial contracture management with mouth opening exercises and splinting showed that patients had significant improvement in vertical and horizontal mouth opening during the course of their treatment.
If perioral contracture is not managed in the initial setting, the resultant microstomia is challenging to address surgically and requires excision and grafting which typically does not produce a favorable cosmetic outcome.
Cicatricial ectropion is a very common complication in patients sustaining periorbital burns (Figure 6). Scarring of the eyelids can lead to ocular complications including corneal ulceration, exposure keratitis, and epiphora.
Conservative measures to prevent ectropion are limited, but keeping the eyes moist using ointments, using moisture devices or tarsorrhaphies to minimize exposure can prevent ocular damage.
Early scar release and skin grafting with full thickness skin grafts is recommended in the cases of eyelid contracture given the important role of protecting the eye.
Multiple procedures for scar release and skin grafting may be required to achieve a functional result because of the nature of the thin skin of the eyelids.
Skin burns of the head and neck are potentially devastating injuries that can have myriad long-term psychological and functional sequelae for the patient. The initial assessment of burns in this area involves airway evaluation and description of burn depth. Following several days to weeks of conservative management with topical ointments and bedside debridement, patients may require surgical intervention with excision and grafting for partial and full thickness burns. Though there is no strong evidence to guide the timing of surgical intervention, careful nursing care, physical therapy, and excision and grafting all play important roles in minimizing the common and morbid complications associated with hypertrophic scarring and contracture in the head and neck.
Conflicts of Interest
The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.
References
Hoogewerf CJ
van Baar ME
Hop MJ
et al.
Burns to the head and neck: Epidemiology and predictors of surgery.
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