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.
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
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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