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Resident Orientation Manual

Produced by Galveston Shriners Burn Hospital and
The University of Texas Medical Branch Blocker Burn Unit.
Contributors:  Sally Abston MD, Patricia Blakeney PhD, Manubhai Desai MD,
Patricia Edgar RN, CIC,John P Heggers PhD, David N Herndon MD,
Marsha Hildreth RD, Ray J Nichols Jr. MD



Facial Burns
   The face is a highly visible and highly vascular region.  It houses all 5 senses.  Mimetic muscles in the subcutaneous plane insert onto skin, producing a complex array of emotional signals.  The face, more than any other feature, is responsible for how the world views each of us and, in turn, how we interpret our world.  Due to these distinctions, management of the burned face takes on important functional, psychological, and cosmetic considerations.

   Unlike deep burns elsewhere, burns of the face are mostly handled conservatively.  Wounds are treated open with ointments.  Since significant invasive infection of facial wounds is uncommon, attention is directed to maximal preservation of vital tissue.  Although some burn surgeons have reported improved cosmetic results with early excision and grafting of the burned face, most prefer to wait 14-21 days.  If wounds do not heal, careful tangential excision is performed.  Facial burns are preferentially skin grafted using sheets from above the blush line.  This is at the level of the nipple.  Skin from this region has a more reddish hue for better facial color match, while skin taken from below the blush line acquires a subtle yellowish hue.  If the entire face is resurfaced, then donor site location is less important.  Facial burn wounds are grafted in aesthetic units.  If available, thicker split-thickness grafts (0.012-0.018 in.) are used to reduce subsequent scar contraction.  Full-thickness grafts are preferred for the lower lids following early release of the burn ectropion.

   If the periorbital regions are burned, the corneas should be carefully examined with fluorescein staining and Wood's lamp.  The eyes should be irrigated with pH balanced saline solution to remove chemical irritants and particulate matter.  In the event of corneal injury, or with severe burns of the lids, an ophthalmologist should be consulted.  Application of ophthalmic antibiotic ointment reduces risks of corneal drying and infection.  Early tarsorrhaphy should be avoided as it increases lid deformity and prevents serial examinations of the corneal surface.  We recently published a paper demonstrating that early burn scar contracture release of the eyelids reduced the risk of corneal ulceration.

   Ear burns are generally treated conservatively with topical antibiotics to preserve tissue.  Deep burns of the external ear predispose the auricular cartilage to chondritis and necrosis, resulting in late ear deformities and tissue loss.  Since chondritis necessitates debridement of the involved tissue, treatment of burned ears should focus on its prevention.  Deep ear burns are treated with topical mafenide ointment for greater eschar penetration.  Avoidance of any pressure on the burned auricle is essential (no pillows).  Pressure is the biggest co-factor in the production of chondritis.  Most ear burns will respond well to conservative treatment, although occasionally immediate coverage of exposed cartilage with a temporoparietal facial flap and skin graft can salvage the ear.

Hand Burns
   Burns involving the hands have a high functional significance secondary only to facial burns.  Most hand burns spare the palm due to involuntary fist clenching at the time of burning.  Palmar full-thickness wounds have a poor prognosis.  In full-thickness dorsal hand burns, functional results are similar for conservative and early excisional therapy as long as aggressive physiotherapy is initiated early.  Initially, escharotomies of the extremities should be completed as necessary and the hands elevated.  The hands are splinted in the neutral position, the thumbs abducted, wrists extended, MP joints flexed to 70-90 and IP joints extended at 0.  Wounds are covered with an antimicrobial cream or biological dressing.

   During tangential excision of hand burns, dorsal hand veins and tendons, especially over the PIP joints, should be spared.  For dorsal hand burns, it is imperative that metacarpal phalangeal and interphalangeal joints are positioned in full flexion prior to graft application.  Palmar excision and grafting is delayed, and performed after dorsal wound closure completed.  Sheet grafts are preferred, but 2:10 mesh is acceptable.  We begin gentle active range of motion exercises on post-operative day 5.

Other Regional Burns
   Full-thickness burns of the scalp are less frequent as skin thickness and hair coverage are somewhat protective.  In massive burns and facial burns, we prefer the unburned scalp as a primary donor site.  Small full-thickness burns of the scalp can be excised and closed primarily.  Larger burns can be skin grafted if periosteum is viable.  If the surface of the calvarium is completely avascular, the outer table of the skull can be removed and the wound allowed to granulate prior to grafting.  Secondary reconstruction of scalp defects with tissue expansion and flaps can re-establish a more normal hair pattern.

Burns of the perineum are unusual with major burn injuries.  Many perineal burns will heal by contraction if kept clean, and healing by secondary intention gives acceptable results.  Colostomy is not necessary.  Burns of the penis may cause more problems secondary to contracture.  Penile full-thickness burn may be conservatively debrided and grafted to minimize contractures.  Revisions following grafting for penile burns are frequent.

   In women, burns involving the breasts have important psychological and cosmetic implications.  Sheet grafts are preferred for coverage.  Nipple burns will often re-epithelialize from the lactiferous ducts, and conservative management is indicated.  Deep burns involving the trunk in young females most often spare the breast bud, which should not be included in the excision specimen.  Scars constrict growth and hinder development, so breast scar release of maturation is indicated.


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