alopecia. The wound care and shaving often has to be undertaken under general anaesthesia particularly in the paediatric patient.

Tangential excision of the scalp is usually accompanied by significant bleeding and most surgeons would avoid this in wounds that have undetermined healing potential. Formal excision is preferred once it is obvious that the injury has no healing potential and/or does not heal. In either case it is not uncommon for the calvarium to be exposed especially in those cases of catastrophic injury. Exposed calvarium poses a difficult management problem especially in a patient with a major burn injury [40]. Traditionally conservative wound care with topical antimicrobials has been used until there is sequestration of the outer table of calvarium leaving a granulating wound bed which is then skin grafted. Drilling holes in or burring off the outer table of skull, which promotes the granulation process, can accelerate this process. This can then be covered either with autograft, allograft or In tegra .

Alternatively free tissue transfer may be used for these difficult cases and can be particularly useful in catastrophic facial burn injury.

The neck

The neck should also be considered as an important area adjacent to the face. Burns in this area are generally treated to a similar fashion to other areas of the body. Surgical excision of deep burns is undertaken early and it is priority area for early autologous skin grafting to achieve early wound healing, particularly in the pre tracheal area if prolonged ventilation is predicted and a tracheostomy is being considered.

Catastrophic injury

Facial burn injury that is both extensive and very deep involving destruction of important facial landmarks can be classified as being catastrophic. This type of injury is usually present in an extensive body surface area burn and its associated organ dysfunction and critical illness. Management of this type of injury involves repeated wound debridement, repeated allograft applications, the use of skin substitutes, the use of early microsurgical reconstruction

C

A B

E

D F

Fig. 5. Catastrophic complex facial burn in patient with 75% full thickness injury.

A On admission;

B Following excision at 5 days post burn and allograft application;

C Resurfacing with Integra;

D 2 months post injury, face healed but extensive area exposed calvarium;

E Coverage exposed calvarium and initial nasal reconstruction with LatissimusDorsi Free Flap and Integra

FLate appearance 3 years post burn following reconstruction with scalp tissue expansion, lip resurfacing with full thickness skin graft, Free Thoracodorsal Artery Perforator (TAP) Flap nasal reconstruction

for preservation of vital structures and tissue salvage. These injuries present an extremely complex challenge usually in the presence of an already complex injury, which requires significant effort in planning and execution to optimize appearance and function. This group of patients may suitable for reconstruction with composite allo-transplantation [41] (Fig. 5).

Post healing rehabilitation and scar management

Rehabilitation of the burn patient begins on admission. This is as true for the patient with a facial burn

as it is for any burn patient. The patient is assessed following admission by the whole multidisciplinary team including the surgical and therapy staff [42]. During the inpatient stay and treatment facial mobilisation, oral food and fluid intake (if possible) and the prevention of microstomia are important aspects of care. Following healing and prior to discharge the patient must be evaluated and a plan made as to ongoing therapy needs and scar management. The therapists must assess the face and document any areas of concern and potential for scar hypertrophy, deformity or developing contracture.

The most commonly used interventions include skin moisturizing, massage, pressure and topical applications of silicone. In particular patients are advised to avoid excessive sun exposure and to use sunscreen cream to prevent hyperpigmentation of the scars.

Silicone sheets have been used for many years to soften the scar, prevent contracture and increase mobility. The most likely mechanism of action is hydration of the scar by occlusion, thus improve the texture, thickness and colour of hypertrophic scars [43].

Massage is universally thought to be a key therapeutic intervention to encourage scar maturation, softening, pliability and fading. Few studies have been undertaken to evaluate the delivery, timing, intensity and duration of scar massage and have produced conflicting evidence as to efficacy [44]. Pressure therapy in the form of a mask or garment is usually indicated in deep partial thickness or full thickness burns following adequate wound healing or in more superficial injuries that begin to form scar hypertrophy. The evidence for the use of pressure is limited however most clinicians believe in the benefits of pressure in terms of the scar maturation process [45].

Facial pressure is difficult to achieve due to the complex convexities and concavities of the face. One option is to combine pressure garments and silicone inserts or sheeting. Another is to make custom made masks that can be lined with silicone. These masks have been traditionally made using a facial mold but more recently they have been made using computer aided design [46]. Both garments and masks can be total or partial depending on the distribution of the

scar. Pressure therapy and scar management are usually continued until the scar matures fully or stops maturing and patients must be warned that this may take up to two years post injury.

Microstomia splints and nasal dilators can be inserted via the nasal and oral apertures of the pressure garment or mask. Compliance with therapeutic interventions and orthotic devices is often a problem, especially with oral splints. A variety of modalities must be used and tailored to the patient’s needs and compliance.

Outcome and reconstruction

The aim of both acute care and subsequent reconstruction in facial burn injury is the restoration of form and function and the amelioration of any discomfort.

In general burn injury gives rise to the following sequealae: hypertrophic scarring, scar contracture, skin colour and texture change and loss of body parts. Although these features apply to all patients, their combination results in unique injury patterns and disfigurement.

Donelan has defined characteristic sequaelae of facial burn injury to include: lower eyelid ectropion, short nose with alar flaring, short retruded upper lip, lower lip eversion and inferior displacement, flat facial features and loss of jaw line definition.

Donelan has classified facial burn categories into 2 general types: Type I – Normal facies with focal or diffuse scarring +/− contractures. Type II – Pan facial burn deformity with some / all stigmata of facial burn deformity [3].

Such characterisation and classification are useful in defining deformity and helpful in planning surgical interventions. Timing of intervention depends on the urgency of the problem and traditionally reconstructive surgery has been delayed until scar maturation is established although more recently early reconstruction has been advocated.

Planning reconstruction requires a realistic approach from both the patient and the surgeon to harmonise expectations with the probable outcomes following surgery. Facial burn reconstruction starts on admission and good primary care will often obviate the need for secondary reconstruction (Fig. 6).

A B

C D

Fig. 6. Appearances of sheet grafting of face using aesthetic units over time.

A 2 years post injury; B 4 years post injury; C 6 years post injury; D 8 years post injury

Summary

Management of facial burns continues to be a difficult and challenging area in burn care. The strategy and options for treatment are debated, in particular about the timing of excisional surgery. For indeterminate depth burn injury a consensus view of topical antimicrobial treatment and observation undertaken until the burn declares itself in terms of healing within a three-week period. Once it is clear the wound will not heal within this time frame excisional surgery is indicated. Early excision and grafting are indicated for those injuries that are obviously full thickness to improve function and outcome.

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for Plastic Surgery and Burns, Court Road, Broomfield, Chelmsford, Essex CM1 7ET, UK,

E-mail:Jorge.Leon-Villapa los@chelwest.nhs.uk