It is our practice to use endo or naso tracheal tubes in patients with partial thickness burn injury that require short to medium term ventilation (> 14 days). Patients who have a pan facial full thickness burn, who require long term ventilation and have an associated major burn (> 60%) TBSA are usually managed with a tracheostomy [11]. This allows easy access to the face for wound and graft care, prevents shearing and allows the benefits of sedation reduction associated with tracheostomy. However this may increase the incidence of subsequent neck contracture when associated with a deep neck burn.

If an endo or naso tracheal intubation is preferred, the tube can be secured by standard tube tapes, however, these make wound care difficult and can rub against the cheek wound deepening it. Our preferred method in this circumstance is dental wiring or a trans-septal silk suture that secures the tube without the need for tapes. Other tubes can be secured in this way or alternatively to the endotracheal tube once it is secured.

Facial burn wound management

Initial wound care

Following admission patients with facial burns undergo cleaning with an antiseptic and debridement of debris and blisters. Superficial partial thickness wounds are cleaned twice daily and a topical antimicrobial is applied until epithelialization and healing occur. Deep burns are cleaned and dressed twice daily with Flammazine or Acticoat on alternate days until surgical excision is undertaken, usually within the first 5–7 days following admission. In indeterminate injury a topical antimicrobial such as twice daily Flammazine or alternate day Acticoat is applied until an assessment is made at or before day 10 to determine whether healing will occur by day 21. This cleaning and debridement may require a general anaesthetic in the operating theatre to adequately clean the wound, remove pseudo eschar and assess the underlying wound.

Conservative management is continued if the wound is believed to heal within 21 days, if not the patient is prepared for surgical debridement and wound closure. In male patients regular shaving of

the beard area prevents excessive accumulation of hair and wound debris that if left can lead to folliculitis, infection and deepening of the wound.

Topical agents

There are many topical agents that have been used in the management of facial burns. These include antiseptics, antimicrobial agents and dressings [12].

Antiseptics are topical agents designed to limit (bacteriostatic) or eliminate (bactericidal) the presence of microorganisms in the surgical wound. They are the mainstay of wound cleansing both following admission and afterwards during repeated wound bathing and cleaning. They include chlorhexidene and povidone iodine products that have similar anti gram-positive, gram-negative bactericidal and viricidal effects. The iodine-based antiseptics are also active against fungi, spores, protozoa, and yeasts. Iodine based preparations can be painful and irritating and in the past have been associated with toxicity [13].

Antimicrobial agents are topical agents that control and limit burn infection. The characteristics of the ideal prophylactic topical antimicrobial agent include a broad spectrum with long standing action, lack of toxicity and adequate local eschar penetration without systemic absorption. They should be inexpensive, and easy to apply and store. They need to provide a favorable wound healing environment and deliver a high concentration of active principle to a devitalized, devascularized and potentially necrotic wound [14]. The use of topical antimicrobials in facial burns is intended to limit bacterial colonization and invasive infection, which has a detrimental effect on the zone of stasis injury leading to deepening of the burn wound.

Silver preparations and silver sulfadiazine in particular are key products in burn surgery as they act on the potentially infected burn eschar limiting the extent of the non-viable tissue but can be irritant, stain the skin and can be absorbed systemically [15].

Silver sulfadiazine cream 1% (Flammazine1, Smith and Nephew; Silvadene1, King Pharmaceuticals) is a water-based cream containing the insoluble active principle silver sulfadiazine in micronized form. Fox introduced it in 1968 and at the time

revolutionized burn wound management. It must be applied repeatedly at least every 12h with a layer thickness of about 3–5 mm and provides effective local antibacterial effect against gram-positive bacteria, gram-negative bacteria, viruses and fungal species such as candida albicans.

It can produce a transient consumptive leucopenia, methahemoglobinemia and is contraindicated in cases of sulfa allergy. Its use can produce a thick yellow pseudo-eschar that can make the differential diagnosis with full thickness burns difficult. It can delay wound healing due to keratinocyte and fibroblast inhibition rendering its use in facial burns questionable although the evidence in this group of patients is limited [16].

Comparison of the use of silver sulfadiazine against bio-engineered skin substitutes showed a significant decrease in wound care time, pain and re-epithelialization time in the skin substitute group [17]. A similar report comparing silver sulfadiazine and allografts found decreased re-epithelialization time and hypertrophic scar incidence in the allograft group [18].

Cerium nitrate can be combined with silver sulfadiazine (Flammacerium) and has excellent penetration, forms a hard eschar and reduces bacterial colonization with gram positive, gram negative and fungal species [19]. Its use has been popularized in Europe with varying results [20] and the results of a randomized controlled study comparing it to Flammazine in the management of facial burns are awaited (ClinicalTrials.gov IdentifierNCT00 297 752).

Acticoat (Smith and Nephew, Hull, UK) is a bilayered polyethylene nanocrystalline silver-based dressing attached to a soaking coat of polyester. It delivers silver at a regular rate to the wound once it becomes saturated with water, avoids the rapid neutralization of silver occurring in other silverbased preparations and limits the need for dressing changes. It needs to be kept hydrated with water. Acticoat is useful in the management of facial burns and is a successful alternative to traditional silver sulfadiazine [21]. It has been compared to silver sulfadiazine and was noted to reduce grafting requirements [22].

Neosporin, Polysporin and Bacitracin are commonly used antibiotic ointments in North America for the treatment of superficial burned areas. Their

eschar penetration is limited. The Neosporin contains bacitracin (gram-positive activity) and neomycin and polymyxin B (gram-negative activity) [23].

Moist exposed burn ointment (MEBO) has been popularized in the Far East and Middle East recently. It contains herbs in a wax ointment but it is not clear what the active ingredient and comparative studies have shown varying results [24, 25].

Beta-Glucan preparations have been reported as reducing pain and promoting healing with Glucancollagen being reported as being useful in partial thickness burns in children [26].

Biological dressings

There are a number of biological and semi-biological dressings that can be used to physiologically close the burn wound to aid epithelialisation in partial thickness injury and to protect the deeper, excised wound from desiccation, infection and mechanical trauma [27].

Prior to application of any of these dressings the wounds need thorough cleaning, decontaminating and debridement of blisters, debris and devitalized tissue. This can only be adequately achieved in most cases under a general anaesthetic in a dedicated facility.

A popular semi-biological dressing Biobrane has been popularized in the management of superficial partial thickness wounds. It is a bilaminar dressing with an external silicone layer bonded to a nylon mesh impregnated with porcine collagen. It has been shown to have advantages over conventional open technique topical management in terms of ease of care, reduction in costs, decrease of pain and decrease in time to healing [28, 29] (Fig. 3).

Cadaver allograft can be used to physiologically close partial thickness wounds. to enhance epithelialsation and healing. A prospective study demonstrated cadaver allograft to be superior when compared to open treatment with silver sulphadiazine. in shallow and deep partial thickness burns [18].

Porcine skin xenografts can also be used for temporary physiological wound closure to promote epithelialisation and healing or as interim prior to autografting [27].

Human amnion can also be used a biological dressing to physiologically close the wound and pro-