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Every year, burn injury cases represent more than 100,000 hospitalizations in the US. More than half of these burn injuries involve the head and neck areas which are caused by flames, chemicals, hot substances and electrical currents. Facial burn injuries may differ from minor burns to serious debilitating injuries.

Facial burns may cause problems with speech, breathing, neck mobility, oral continence, and sight. There are distortions on the facial features like contractures, scars, and discolorations that may also affect a patient’s overall appearance.

While most scars on the body can be hidden with reasonable effort, scars from facial burn injuries are highly noticeable. Preventing the formation of facial scars is one of the main goals when treating burn patients. A burn patient may require challenging facial reconstruction procedures and may need to be assisted by different medical specialists.

Reconstructive surgery for a facial burn injury is done to restore the function, appearance, and well-being of a person.

Assessment of facial burn injuries

An in-depth evaluation of the facial skin anatomy and degree of damage is made before facial burn injury is treated.

By: Dr. Robert M. Kimmel

First-degree facial burn injury

First degree burns are usually superficial burn injuries which involve minimal tissue damage. The injury appears pinkish, dry, and without blisters. It’s often painful which may be caused by scald, sunburn, or flash flame. The burn site may heal for about 5 to 10 days. Typically, there’s no scar formation, but skin discoloration may occur.

Second-degree facial burn injury

In this classification, the top-most layer of the skin and may be a portion of the dermis is damaged. The wound site is often painful and appears reddish with blister formation. With proper treatment, the affected site may heal for about 10 to 14 days. However, deeper second-degree burns may take at least 30 days to recover. Utmost care must be given on a second-degree burn as it may develop into a third-degree injury if infection occurs.

Third-degree facial burn injury

Almost the entire skin may be damaged in a third-degree burn injury. The sensory nerve endings of the affected site are also destroyed, so pain on the injury site isn’t felt.

Formation of blisters and eschars is common. The skin appears dry and leathery with a gray, white, brown or black discoloration. Most severe burns fall in this classification and healing doesn’t occur spontaneously. Third-degree burns may result in disfiguring scars, loss of senses, and severe deformities.

Surgical treatment for facial burn injuries may be given to second and third-degree burns, depending on the extent of the injury.

person in blue and white plaid shorts

Choosing the right facial burn plastic surgeon

A facial burn surgery must be done by a certified and expert cosmetic surgeon to accomplish the best results. An unqualified practitioner may lead to surgical complications and unsatisfying results. Keep these factors in mind when choosing a surgeon for facial burn surgery.

  • Certification and Memberships. Facial burn surgery is a challenging procedure as it involves the reconstruction of important facial features. Make sure that the cosmetic surgeon is a certified member of the American Board of Plastic Surgery. Memberships may not be necessary, but it could be a great indication that the surgeon is well-skilled.
  • Experience. A plastic surgeon’s experience can tell if the surgeon can give a safe and successful facial burn surgery.
  • Reputation. One way to find an excellent plastic surgeon is by seeking a recommendation. If you know someone who went through a facial burn surgery, ask them. Check the doctor’s record for any malpractice complaints. This information may be made public by state medical boards.

Initial evaluation

The initial evaluation and treatment of facial burn injuries should follow the same systematic approach as for all trauma patients. Doctors will ask about personal details and other relevant information so that a definitive treatment will be made on a burn patient. Head and neck burns are prioritized because of further potential injuries on airways that might occur.

Patient’s age, underlying medical conditions, drug or alcohol intoxication, and circumstances surrounding the burn injury, are to be taken into consideration for proper medical and surgical intervention.

The plastic surgeon or staff will discuss in details with their patient and their family on the extent of the injury, surgical procedure, and the realistic goals of the surgery. After the patient fully understands what’s being discussed, a waiver or consent form will be signed as a confirmation to undergo a facial reconstructive surgery.

The patient is ensured that perseverance and patience will be required during the long reconstructive process. It’s important that the surgeon’s instructions and advice must be observed as the reconstructive process may take several years to finish. The burn patient must also realize that he or she won’t be able to acquire the exact pre-injury appearance after a successful facial reconstruction surgery.

Initial treatment

A patient with severe burns is first treated with fluids intravenously to obtain proper hydration of the body. Depending on the extent of burn injury, a patient may be treated on an inpatient or outpatient basis. The surgeon usually decides on this matter.

The burn site is cleansed thoroughly, and appropriate wound care is given to the patient. An antibiotic is then applied to the burn site to prevent infection.

The doctor will give instructions for wound care. Therapy for local wound care may be recommended for about 10 days after injury. During this period, many facial wounds heal quickly because of the excellent blood circulation in the face region and faster skin cell rejuvenation.

If wounds haven’t healed by 10 days or are clearly third-degree burns at initial assessment, no benefit is obtained by further delaying. These wounds are at risk of developing scars which may require undergoing excision and grafting.

Other considerations during this initial period include:

  • Flap coverage of exposed bone or cartilage
  • Protection of exposed corneas
  • The release of the mouth or neck to allow proper eating and speech.

Exercise and stretching are recommended in patients with second and third-degree facial burns soon after hospital admission. They’re essential in managing facial contractures effectively.

Facial burn surgical approaches

Proper planning of facial burn surgical treatment is necessary to acquire satisfactory and desirable results. Priorities have to be established like putting facial functioning issues first before aesthetic concerns. Allocating potential donor sites are also to be taken into consideration when setting priorities for facial burn surgery.

The patient is permitted to set the priorities. But, he or she will be assisted by the surgeon in regards to expected benefits and proper scheduling of surgical procedures. After a thorough discussion, a well-planned flow of surgical procedures will be created. However, the plan may be changed as the treatment progresses depending on the patient’s condition.

Facial burn surgery may start at the time of a facial burn injury. But the earliest fundamental concern before any facial reconstruction surgery is to achieve a completely healed wound.

Surgical techniques for facial burn surgery

General procedure

Certain standards are necessary when dealing with facial burn injury reconstruction. Some doctors recommend doing the same reconstructive procedure for each side of the face to achieve symmetry. However, this approach may only be applicable if the entire face needs reconstruction.

Initial treatment is made after the scars have matured and contractures occur on the applied skin grafts. The scars may result in a patch-like appearance. Raised scars may occur in wounds that take more than 2-3 weeks to heal. If this happens, a scar revision or staged excision may be needed.

Things to do before a facial burn surgery treatment:

  • Antiseptic bath and application of an antibiotic ointment are to be done daily for 10 days.
  • Address to the plastic surgeon wounds that won’t likely heal within 14 days of injury.

A definitive treatment may be considered once the patient is found to have a deep facial burn injury. The plastic surgeon will decide which surgical procedure is appropriate for the deep burn injury. Depending on the extent of the injury, the plastic surgeon may consider surgical procedures like healing by primary closure, granulation, free skin grafts, local, regional, or distant skin flaps. If the burn injury is clearly a third-degree burn, excision and grafting may be done within 7 to 10 days.

Facial burn surgery is a very challenging procedure, and a careful surgical technique is important to achieve desirable results.

Antibiotics may be administered before surgery. The patient’s eyes are protected by placing corneal protectors. A lubricating ointment is also applied on the patient’s eyes. Then, anesthesia is administered by the doctor to prepare the patient for facial burn reconstructive surgery.

For facial burn injury reconstruction, the patient’s face is first cleansed with diluted Betadine® or saline solution. The plastic surgeon carefully removes damaged tissues and meticulously stops the flow of blood to the affected areas. Removal of damaged tissues by cauterization isn’t recommended as it might devitalize tissues. Gentle pressure or application of a topical vasoconstrictor like epinephrine is usually done to achieve a good hemostatic control.

In facial burn reconstruction surgery, early excision and grafting are the commonly used surgical treatment. This procedure may be done in 1-2 stage technique. Other facial burn reconstruction techniques include:

  • AlloDerm – Skin cell components that cause rejection are removed from a donated (cadaver) human skin.
  • TransCyte – A temporary skin substitute used is derived from a human fibroblast.
  • Integra – A temporary silicone skin substitute and an artificial dermal layer are used. The neo-dermis usually forms for about a month. Then, the silicone layer is taken out and replaced with a very thin split-thickness skin graft.

Skin grafting

Skin grafting is the easiest method for facial burn reconstructive surgery. It’s usually the preferred technique for burn injuries that involve large full-thickness or deep partial thickness defects. In this surgical procedure, it’s important to put the face’s donor site aside before all donor sites are used to restore other body parts.

The patient should have realistic expectations when undergoing this procedure. Even the best full-thickness graft may lose some of its natural skin qualities. Changes in the skin’s texture and pigmentation may also occur. But, the good thing about skin grafts is that they aren’t bulky, so they don’t mask facial expressions.

Full-thickness skin grafts

Full-thickness grafts involve the epidermis and the entire dermis. The plastic surgeon carefully harvests from discreet donor sites that easily close or heal. They may be taken from the upper eyelid, nasolabial fold, pre-auricular and post-auricular areas, and the supra-clavicular fossae. These donor sites are often used to close facial or neck burn injuries or to resurface existing scarred areas.

Split-thickness skin grafts

Split-thickness skin grafts include the epidermis and part of the dermis. Its thickness depends on the donor site and the needs of the person receiving the graft. It can be prepared through a skin mesher which creates spaces on the graft. This method allows the graft to grow up to nine times its size. Split-thickness grafts are often used in facial burn reconstructive surgeries as these grafts can cover large areas and the rate of auto-rejection is minimal. After 6 weeks, the surgeon can harvest from the same donor site. The donor site usually heals by the regrowth of the skin cells of the dermis and surrounding skin.

Composite skin grafts

Composite skin grafts are usually a small graft consisting of skin and underlying cartilage or other tissue. The donor sites for composite skin grafts include the ear skin and cartilage to restore nasal defects.

In addition to skin grafting, regional flaps, free tissue flaps, and tissue expansion are taken into consideration by the surgeon for patients with larger facial burn defects.

Regional flaps

Regional and transpositional flaps provide adjacent and damaged tissues with blood supply. An advantage of doing this procedure is that it achieves skin of similar quality and pigmentation as with the burned site. These flaps are generally thin and flexible, but they’re not as thin as skin grafts.

Free tissue flaps

Free-tissue flaps may be needed to cover a patient’s exposed bone or cartilage. It can also be used to introduce extra tissue when local tissues or skin grafts are inadequate or rejected.
There’s a 94% success rate for head and neck reconstruction using free tissue flaps.

Some of the commonly used free tissue flaps for facial burn reconstruction surgery include the abdomen, arm, and groin areas. Free tissue flaps aren’t usually a first-line surgical treatment because it has disadvantages, like the complexity of the surgery with microvascular anastomosis. However, it’s an important supplementary procedure when needed.

Tissue expansion

Tissue expansion technique is a surgical procedure that allows the patient’s body to ‘grow’ extra skin which will be used for reconstructive surgeries like facial burn surgery.

Advantages of tissue expansion

When the body is allowed to grow extra skin, the generation of new tissues will have similar qualities with the burned site.

Other advantages of this surgical procedure are the following:

  • Tissues generated are similar to the defect in color, texture, and thickness.
  • Donor sites aren’t required
  • Tissue expansion allows larger donor sites for full-thickness skin grafts. Harvesting of relatively large full-thickness grafts is possible
  • Skin grafts generated by tissue expansion behave like smaller, non-expanded full-thickness grafts

Disadvantages of tissue expansion

  • Additional surgeries are required
  • Needs a longer time for the tissues to generate or expand

Face transplant (human partial face allograft)

Some patients may have severe facial burn injuries. Face transplants may be the best solution for their facial burn injury concerns. However, this surgical procedure involves a lot of risks and disadvantages. There’s a high risk of rejection, and the patients are required to take immunosuppressants. Someday, science and technology will make incredible developments on this procedure that’ll benefit those severely disfigured burn patients.

Scar revision

Scars are actually visible signs that surgical wounds have healed. Scar revision surgery helps minimize the development of scars on surgical sites. It’s done to make the developing scars less visible and may blend in with the surrounding skin.

Non-surgical techniques for facial burn surgery

Non-surgical techniques for facial burn surgery include scar massage, usage of pressure garments, and cosmetic camouflage.

Dermabrasion is also a convenient non-surgical method for reconstructing old facial burn scars.

What happens after a facial burn surgery?

After surgery, the patient mustn’t expect immediate results as reconstructive surgeries take at least a year to achieve visible results. As the healing progresses, changes in the color and appearance of the skin at the surgical site will be noticed. Numbness or a tingling sensation around the surgical site may also be felt. These feelings are normal but will typically subside over the next few months.

Development of scars may start within 3 weeks following a facial burn reconstructive surgery. Hypertropic scars are most evident over the next 3 months. The scars are mostly raised, red, and itchy. These scars then slowly regress during the following 12-24 months. After some time, mature scars which are white, soft and flat remain or may become permanent.

After surgery, the plastic surgeon will provide instructions which need to be followed to avoid complication and achieve desirable results. Some of the instructions given are:

  • Continuous use of pressure garments or masks early after surgery
  • Start massaging the scars as soon as the healing of wounds occurs
  • Apply moisturizing sunscreen or sunblock and avoid exposure from direct sunlight for the first 12 months. This avoids potential complications with hyperpigmentation.
  • The surgeon may prescribe antibiotics and pain medications. Make sure to follow the doctor’s advice when taking meds strictly.

After your facial burn reconstructive surgery, it’s important to carefully monitor the passage of fluid and blood circulation of the surgical site. The patient is advised not to wear tight-fitting clothes or clothes that put pressure on the surgical site. Additional instructions for monitoring will also be given to the patient by their plastic surgeon. Make sure to follow the instructions to avoid risks of complications or infections.

Signs and symptoms of infection at the surgical site

When undergoing a facial burn reconstructive surgery, one must be very careful about signs and symptoms of a possible infection. The patient must inform their plastic surgeon immediately if any of the following signs and symptoms is felt:

  • Fever
  • Sweats or chills
  • Rashes
  • Tenderness, redness, or swelling of the surgical site
  • White pimples or blisters around incision lines
  • Discharges from the surgical site
  • Pain that isn’t relieved by prescribed pain meds
  • Nausea, vomiting, or diarrhea
  • Sore or scratchy throat or pain when swallowing
  • Persistent, dry or moist coughing that lasts more than two days
  • White patches in your mouth or on your tongue
  • Burning pain when urinating or frequent urination
  • Bloody, cloudy, and foul-smelling urine

You may experience some other signs and symptoms of infection that might need immediate medical attention. If you notice any telltale signs and symptoms of infection, it’s important that you call your doctor as soon as possible.

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