A B

Fig. 3. Indeterminate depth facial burn treated conservatively with Biobrane.

A Following biobrane application; B At 3 months

mote epithelialisation and healing. A recent randomized controlled study comparing amnion to standard topical antimicrobial care showed a reduction in healing time, reduction in the amount of reapplications of facial dressings in the amnion group, but no difference in scarring [30].

A recent literature review compared and analyzed bioengineered skin substitutes with biological dressings and topical management and found similar efficacy in the three options [31].

Surgical burn wound excision of the face

Once the decision to operate is made surgical excision of the facial burn should proceed on the next available operating list if the patient’s condition permits and there are no other areas with greater priority to excise.

A team used to undertaking such surgery must undertake the procedure. Preparation is of vital importantance. The operating theatre staff should be informed of the nature of the surgery and to ensure that homografts and skin substitutes are ordered and available. Blood must be cross matched preoperatively and be available in the operating theatre before commencing surgery as blood loss can be massive. Prior to commencing surgery the WHO patient safety checklist should be run through to minimize avoidable complications [32].

The operation is performed with the patient supine in the reverse Trendelemburg

position under general anesthesia. Prophylactic perioperative antibiotics are given.

The endotracheal tube should be suspended together with feeding tubes from an overhead hook to keep the tubes out of the operative field. Care must be taken to protect the eyes with silicone pads or temporary tarsorraphy stitches.

Depending on the size and the depth of the burn, facial burns can be excised and resurfaced either in one, two or multiple stages.

Isolated deep facial burns can be excised and autografted in one operation. A one-stage dermal skin substitute (Matriderm /Integra ) may be considered in this type of injury to provide dermal replacement without prolonging inpatient stay. Immediate autografting is feasible if thorough debridement and meticulous hemostasis can be ensured [10].

In larger body surface area and deeper burns repeated debridement with cadaver allograft or skin substitute wound closure to ensure adequacy of debridement and hemostasis. This principle of repeated or second look surgery performed within 4–7 days allows for thorough and adequate debridement with re-excison of non viable tissue, perfect hemostasis and prevention of graft loss due to hematoma (Fig. 4).

Hemostasis is aided by subeschar infiltration of 1/1,000,000 solution of epinephrine and topical application of 2% phenylephrine soaked swabs. The authors believe this technique limits blood loss, and does not lead to over excision of the burn wound.

The aesthetic units that will not heal within 3 weeks of the injury are outlined with markers. These are surgically excised in a tangential fashion. In some aesthetic units small areas of normal skin or superficial wounds can be excised to conform to the unit.

If only a small area of an aesthetic unit is burned it can be debrided and grafted leaving the adjacent uninjured normal tissue. This may require reconstruction at a later stage.

In areas of mixed depth burn injury excision should aim to be at a uniform depth to remove any skin appendage remnants to prevent subsequent problems with buried hair follicles and associated pits, cysts and infection.