Facial Burns

Facial burns vary from relatively minor insults to severe debilitating injuries. Over 50% of burn injuries involve the head and neck region and can be caused by flame, electrical current, steam, hot substances, and chemicals. ^{[1, 2]}

Each year in the United States, US 1-2 million burn injuries demand medical attention. Using the National Electronic Injury Surveillance System, Auh et al found that between 2000 and 2018, an estimated 203,180 patients below age 20 years underwent treatment in US emergency departments for facial burns, the annual average being 130 such burns per million children. Boys made up the majority of cases (66.4%), with 41.9% of patients in the study being under age 5 years. Thermal burns and scalds were the most common burn types (51.9% and 30.7%, respectively). A significant 53.1% decrease was seen in the number of facial burns over the 19-year study period, with a reduction of 69.6% and 63.5% in the number of thermal and radiation facial burns, respectively, but a relatively constant number of scalding burns being maintained over the course of the study. ^[3]

Remember that burn injuries may take the skills of multiple specialties in a burn center. ^[4] Objectives for reconstruction following a facial burn include restoration of function, comfort, and appearance. Functional concerns in these patients include airway patency, protection of the cornea, oral continence, and neck mobility. Burns may impart a tight masklike sensation to the face, distorting features and limiting facial expression. Appearance is altered by contractures, scarring, and pigmentary changes. The goal of the reconstructive surgeon is to minimize final deformity by restoring the patient to a near-normal appearance.

Before caring for a patient with facial burns, a thorough knowledge of skin anatomy and burn classification is essential. Skin covers the entire external surface of the human body and is the principle interface between the body and the surrounding world. Skin serves as a protective barrier, preventing internal tissues from being exposed to trauma, ultraviolet radiation, temperature extremes, toxins, and bacteria. Other important functions include sensory perception, immunologic surveillance, thermoregulation, and control of insensible fluid loss.

The skin is composed of 3 principal layers: the epidermis, the dermis, and an underlying fatty subcutaneous layer. The epidermis and dermis are 2 mutually dependent layers that rest on the subcutaneous layer. The epidermis contains no blood vessels and is entirely dependent on the underlying dermis for nutrient delivery and waste disposal via diffusion through the dermoepidermal junction. The primary function of the dermis is to sustain and support the epidermis.

Epidermal appendages are intradermal epithelial structures lined with epithelial cells with the potential for division and differentiation. These serve an important role as the source of epithelial cells that are responsible for reepithelialization if overlying epidermis be removed or destroyed in certain situations, such as partial-thickness burns, chemical peeling, dermabrasion, or traumatic abrasions. Epidermal appendages include sebaceous glands, sweat glands, apocrine glands, mammary glands, and hair follicles. Sebaceous glands are in highest concentration on the face and scalp (as many as 900 per cm²). Epithelial appendages are located deep within the dermis. In the face, they may even lie in the subcutaneous fat beneath the dermis. The deep location of these structures and their density in the face account for the remarkable ability of the face to reepithelialize even the deepest cutaneous wounds.

Skin varies in thickness based on anatomic location and on the sex and age of the individual. Skin is thickest on the palms and soles (approximately 1.5 mm thick), while skin is thinnest on the eyelids and postauricular region (approximately 0.5 mm thick). The skin of men is characteristically thicker than the skin of women in all anatomic locations. Children have relatively thin skin that progressively thickens until the fourth or fifth decade of life when thinning begins.

A burn involves the destruction of skin cells and sometimes the underlying structures of fascia, bone and muscle. A burn occurs when these structures absorb more heat than their capacity to dissipate. The injury to skin triggers inflammatory responses, and a variety of local cytokines cause a rapid accumulation of extravascular fluid.

Burns are classified by degree or depth of injury. A first-degree burn (superficial) involves minimal tissue damage and is confined to the epidermis. It can be caused by sunburn, scald, or flash flame. The appearance is dry and without blisters, with a pink color that is usually painful. Healing occurs over 5-10 days. Usually, no permanent scar occurs, but the tissue may discolor.

A second-degree burn (partial thickness) destroys the epidermis and a portion of the dermis and is typically painful. These burns can be caused by contact with hot liquids or solids, flash flame, or chemicals. The appearance is hyperemic, but may be pale, and moist with blisters. Although a variable depth of skin is initially lost, most partial-thickness burns, if treated appropriately, spontaneously reepithelialize from epithelial cells residing in remaining epithelial appendages. These burns usually heal in 10-14 days and no grafting is needed. A deeper partial-thickness burn may take more than 30 days to heal and can convert to a full-thickness injury if it becomes infected.

Third-degree burns (full-thickness burns) destroy both the epidermis and the entire dermis and are insensate because of the loss of sensory nerve endings. These burns can be caused by contact with hot liquids/solids, flames, chemicals or electricity. A full-thickness burn is dry and leathery with a gray, white, or translucent color; it turns brown or black in color, characteristic of an eschar. Most of these wounds do not heal spontaneously unless they are very small, and the resulting scars may be quite disfiguring. Operative intervention is indicated in full-thickness facial burns and in some partial-thickness burns.

An initial evaluation and treatment should follow the same systematic approach as for all trauma patients: a primary survey, a secondary survey, followed by definitive treatment. For head and neck burns, the airway is a major concern because of potential inhalational injuries. A study looked at all of the risk factors for inhalational injuries and the need to intubate, and they concluded that patients who present with soot in the oral cavity, facial burns, or body burns should undergo fiberoptic laryngoscopy to look for laryngeal edema because they are much more likely to require intubation. ^[5]

However, a retrospective study by Freno et al of patients presenting with facial burns, soot, or carbonaceous sputum questioned the efficacy of fiberoptic nasolaryngoscopy in deciding whether patients should be intubated. Although nasolaryngoscopy revealed erythema, edema, or carbonaceous debris in 58 of 188 asymptomatic patients (31%), only 2 (1%) underwent intubation. The investigators did suggest, though, that negative results in symptomatic patients may enable select individuals to avoid intubation. ^[6]

Facial burns are frequently associated with other morbidities. Assess the full extent of injury, including the total body surface area involved and the depth of wounding. Keep in mind that the head and neck represent 9% of the total body surface area in adults when using Wallace’s rule of 9s. In neonates, the surface area is approximately 19%, and for each year of age 1% is subtracted from the head and given to the thighs until age 10. This consideration is important in that it informs future decisions regarding the determination of available donor sites for subsequent reconstruction and necessity for other procedures by different specialists. Adequate documentation, including photographs, is essential because facial burn reconstruction is typically a lengthy process involving multiple procedures.

Consider the circumstances surrounding the injury, patient age, significant comorbidities, drug and alcohol use, and available family and friend support structure. These factors influence patients' ability to cope with the severe psychological and social impairment often experienced following severe facial burns. ^[7]

An open and honest discussion with patients and their families should detail the extent of injury and the goals of surgical intervention. Portray results realistically, including what can and cannot be accomplished. This is typically the beginning of a long-term physician-patient relationship and requires compassion, understanding, and guidance. Ensure that patients understand that dedication and patience will be required to endure a long reconstructive process that may take several or more years to complete. Finally, patients must realize that, however successful the reconstruction, they will not be returned to their pre-injury appearance.

For patients with severe burns, fluid resuscitation needs to be initiated using the Parkland or modified Brooke formulas to ensure that urine output is maintained at 0.5-1 mL/kg/hr. ^[8] Ensure patients have appropriate pain control with acetaminophen, narcotics, and/or anxiolytics on a continuous basis. Patients with burns greater than 30% should be transferred to a burn unit. Those patients with burns of 15% or less or third degree burns of less than 2% may be treated on an outpatient basis if all other circumstances are favorable. Others should be treated as in-patients. ^[4]

The aim of initial therapy is to prevent complications. Gently, under appropriate anesthesia, mechanically débride wounds. Do not perform sharp debridement initially, since it is often difficult to determine the exact depth of injury, and such action may injure underlying muscles or nerves. Then apply an antibiotic ointment such as silver sulfadiazine, mafenide (Sulfamylon), silver sulfadiazine, or 0.5% silver nitrate solution; nitrofurazone soluble dressing (Furacin) or a bilaminar temporary skin substitute (Biobrane) is also an option. The early application of Biobrane decreased pain significantly in one study. ^[9]

Most authors recommend conservative therapy consisting of local wound care for approximately 10 days after wounding. Many facial wounds heal rapidly during this period because of the excellent blood supply and high density of epithelial appendages. Initially, estimating wound depth is often difficult. If wounds have not reepithelialized by 10 days or are clearly third-degree burns at initial assessment, no benefit is obtained by further temporizing.

Wounds unhealed within the first 2 weeks have a much higher likelihood of developing hypertrophic scarring and should undergo excision and grafting. Other considerations during this initial period include (1) flap coverage of exposed bone or cartilage; (2) protection of exposed corneas; and (3) release of the mouth or neck to allow eating, communication, and access for subsequent anesthetic administration.

A study by Clayton et al indicated that exercise and stretching initiated in patients with partial-thickness orofacial burns soon after hospital admission can be used to effectively manage orofacial contractures. In the study, 229 patients with partial-thickness orofacial burns participated in a regimen combining exercise and stretching that began within 48 hours of admission and continued for an average of 30.7 days, with significant improvement found posttreatment in vertical and horizontal mouth opening. However, vertical mouth opening among the patients remained significantly more restricted than that recorded in 120 healthy controls, although horizontal mouth opening ability was statistically comparable between the two groups by the end of therapy. ^[10]

Another study by Clayton and colleagues, of exercise therapy in full-thickness orofacial burns, also found improvement in vertical and horizontal mouth opening by the end of treatment, although these abilities remained more limited than they were in healthy controls, and patients required, on average, 550 days of exercise therapy. ^[11]

Appropriate timing of surgical intervention is essential to a successful outcome. Establishing priorities, placing functional concerns before cosmetic concerns, and rationing potential donor sites are key elements of this operative strategy. Allow the patient (rather than the surgeon) to prioritize reconstructive procedures, with the surgeon providing counseling regarding expected benefits and appropriate timing of procedures. Together, an overall master plan may be developed that may need modification as treatment progresses and patient status changes. Whenever possible, reduce anesthetic events by combining complementary procedures and coordinating the various surgical disciplines involved.

Generally, surgical intervention may be categorized as early or delayed; but, in reality, patient treatment is a continuum beginning at the time of injury. The earliest essential concern is to achieve a closed wound. This is necessary before entertaining any thoughts of reconstruction.

General

Certain aesthetic principles are important when approaching reconstruction of the burned face. Reconstruction should proceed within facial aesthetic units. Treat each region (ie, forehead, eyes, nose, cheeks, ears, upper lip, lower lip and chin, neck) as an individual entity. Place scars at the boundaries of 2 aesthetic units. Often, sacrificing normal skin and replacing an entire aesthetic unit is better than replacing part of an aesthetic unit and having a scar coursing across that unit. Orientation of scars parallel to relaxed skin-tension lines (RSTLs) is also important. Some authors even stress symmetry to the point of recommending the same procedure for each side of the face. This may seem reasonable if the entire face were involved but is unnecessary if only part of the face is burned.

Primary repair is elected over waiting for scar maturation and secondary release of contractures that always results in a patchlike appearance on the applied grafts. ^[12] Hypertrophic scarring seems to occur in wounds that take longer than 2-3 weeks to heal. Scar revision or staged excision may still be necessary later, and the patient should understand this at the outset.

Preoperative treatment includes daily antiseptic bath with chlorhexidine 0.05% and antibiotic ointment applied daily. Continue until day 10 and address those wounds that are not likely to heal within 2 weeks of injury. Once diagnosed with a deep injury, definitive treatment must be considered. Options include healing by granulation, primary closure, free skin grafts, local regional, or distant skin flaps. Burns that are clearly full-thickness are scheduled for excision and grafting within the next 7-10 days.

A careful operative technique is essential for a successful outcome. Perioperative antibiotics are administered. Use ocular lubricating ointments or corneal protectors prior to starting the procedure. After administering an appropriate level of anesthesia, prepare the wound for reconstruction. Start with wound cleansing with saline or dilute Betadine, judicious debridement, and achievement of meticulous hemostasis. Good hemostatic control can be gained with ligation, gentle pressure, application of a topical vasoconstrictor (eg, epinephrine), or bipolar electrocautery. Minimize electrocautery, as it creates devitalized tissue. Use of topical or injected epinephrine at the donor or recipient sites does not compromise outcome or tissue survival.

Early excision and grafting is the treatment of choice; it may be a 1-2 stage technique. ^{[13, 14]} Other options include AlloDerm (from cadaver skin, removing all cell components that cause rejection), TransCyte (human fibroblast-derived temporary skin substitute), or Integra (a temporary silicone epidermal substitute and an artificial dermal layer. If Integra is used, the neo-dermis forms in 2-4 weeks. The silicone layer is then removed and replaced with an ultrathin split-thickness skin graft (0.004 in). ^[15] For larger burn defects, one might consider regional flaps, free flaps, and tissue expansion in addition to skin grafting.

A study by Li et al indicated that an integrated approach to total facial reconstruction can be beneficial in patients with postburn full facial deformities. Flap prefabrication, skin overexpansion, and reshaping of the facial contours through multistaged revisions were performed, with the prefabricated flap used to resurface the whole defect. Two patients underwent bone marrow mononuclear cell transplantation. Improvements in aesthetic and functional status scores were achieved, and the investigators reported that patients had good skin compliance, normal contours, and emotional expression. ^[16]

Prioritized Specific Procedures

Skin grafting

Grafting is frequently the preferred choice when large full-thickness or deep partial thickness defects are involved. The propensity of split-thickness grafts for contracture is attributable to their limited content of dermal tissue.

Skin grafting is the simplest way to replace burned facial skin. Setting aside the face’s donor site before all donor sites are used to resurface other body parts is important. Although even the best full-thickness graft loses some of its innate skin qualities, and although textural and pigmentary changes may persist, skin grafts advantageously lack bulk; therefore, they do not mask facial expression. Donor sites for full-thickness grafts are limited, and preoperative planning must consider the most efficient use of these donor sites. Match thickness, texture, pigmentation, and hair coverage as closely as possible. When grafting in children, remember that donor sites (eg, groin, axilla, thigh, chest) sprout hair at puberty, and this hair growth may be undesirable at the new location.

Full-thickness grafts

Choose donor sites for full-thickness grafts that are inconspicuous and that are easily closed primarily. Full-thickness grafts may be harvested from the upper eyelid, nasolabial fold, preauricular and postauricular regions, and the supraclavicular fossae. These donor sites are most often used to close facial or neck wounds or to resurface an existing scarred region.

When harvesting from the face, harvesting bilaterally to maintain facial symmetry is often aesthetically preferable, even if more skin than necessary is removed to cover the defect. Full-thickness donor sites used less frequently include hairless groin skin, dorsum of the foot, wrist-flexion creases, and elbow creases. Scars from skin grafts harvested from the wrist-flexion crease may resemble those seen with suicide attempts and should probably be avoided. Darker-pigmented grafts may be obtained from the prepuce, scrotum, and labia minora. Locations with avulsed or surgically removed skin are potential donor sites that are often overlooked.

Split-thickness grafts

Only use split-thickness grafts if harvested very thick with a significant portion of dermis included. This is because secondary contraction often occurs after split-thickness skin grafting, and the amount of secondary contraction is inversely proportional to the amount of dermis included in the graft. The scalp is a great donor site. For split-thickness grafts 0.018-0.025 inch, the scalp is then shaved. After complete hemostasis is achieved, the autografts are placed in aesthetic units.

Regional flaps

Regional and transpositional flaps introduce neighboring tissue with organic blood supply to the defect and have the advantage of providing skin of similar quality and pigmentation as the burned site. Transposition flaps are generally thin and pliable, although not as thin as skin grafts.

Free-tissue flaps

Free-tissue transfer may be required to cover exposed bone or cartilage or to introduce extra tissue when local tissues or skin grafts are inadequate or contraindicated. Defects greater than two-thirds of the anterior neck require distant tissue and are usually not amenable to local flaps. The most commonly used free-tissue flaps for facial reconstruction include latissimus dorsi, temporoparietal fascia, omentum, rectus abdominis, groin, radial forearm, dorsalis pedis, and parascapular flaps. These flaps require microvascular anastomosis and often subsequent debulking because of their large size. Free-tissue transfer for head and neck burn flap does have a success rate of 94%.

A total-face reconstruction was performed with a bilateral free scapula megaflap, but did result in the appearance of facial masking. Advances such as flap prefabrication, prelamination pre-expansion, chimeric flaps, and super-thin flaps have increased the quality of freeflaps. ^[17] Prefabrication has resulted in thin flaps not requiring debunking in 64% of patients. ^[18] In addition to the extra tissue, the radial forearm free flaps can be made sensate by incorporating the lateral ante brachial cutaneous nerve and attaching it to a branch of the trigeminal nerve. ^{[19, 20]} The free flap is not usually a first-line treatment option with the inherent disadvantages such as the complexity of the surgery with microvascular anastomose but is a valuable adjunct when required.

Tissue expansion

Another reconstruction option is recruitment of additional skin by tissue expansion. Benefits of this technique include generation of tissue that is similar to the defect in color, texture, and thickness. Furthermore, no donor site is created. In addition to standard tissue expansion techniques, tissue expansion has been used to expand the donor sites for full-thickness skin grafts. This allows harvesting of large full-thickness grafts from a relatively small donor area that subsequently may be closed primarily. Grafts produced in this manner behave like smaller, nonexpanded full-thickness grafts. Tissue expansion and free-tissue transfer are commonly used together in reconstructive facial plastic surgery. Tissue expanders are placed under the subcutaneous place between the deep fascia and the muscle layer. Disadvantages of pre-expansion are the need for 2 operations and a significant time period for the progressive expansion. ^[21]

Delayed or Secondary Treatments

Scar revision

Hypertrophic scarring, keloid formation, and contracture leading to disability and deformity continue to be challenging late complications of burn injuries and other traumas. Contractures can lead to permanent skeletal deformities and functional deficits. Methods of release include alphabet plasties (eg, Z, W, Y-V), skin grafts, skin expansion, or regional or free musculocutaneous or fasciocutaneous flaps to achieve adequate functional improvement.

Nonoperative treatments include massage, pressure garments, and cosmetic camouflage. Secondary skin grafting is simple, reliable and safe. Full-thickness skin grafts (groin, thighs, abdomen, postauricular, supraclavicular, upper eyelid, shoulder, cubital fossa) are preferred to split-thickness skin grafts (thigh, arms, buttocks) in postburn contracture releases. ^[22]

Another option is using Integra, which may reduce the number of operations and the time period of treatment required by conventional procedures of multistage scar contracture release. With this technique, allografts were applied to control wound colonization and 48 hours later, the allografts were removed and Integra was applied to the wounds. Eighteen days after Integra application, ultrathin split thickness skin grafts were applied over the Integra dermal layer. ^[15] Dermabrasion is a useful technique for revising old burn scars. ^[23] The ultimate goal for delayed scar revision is symmetry and a relatively normal appearance.

Human partial face allograft (face transplant)

The first of several human partial face allograft transplants occurred in 2005. After 18 months, the surgeons reported the outcome, stating that the patient has sensitivity to light touch and to heat and cold, which returned to normal at 6 months after transplantation. Motor recovery was slower, and labial contact allowing complete mouth closure was achieved at 10 months. Psychological acceptance of the graft progressed as function improved. Rejection episodes occurred twice after transplantation and were reversed. Face transplants still have long-term rejection risks and require immunosuppressants that have inherent risks, such as developing a carcinoma. ^{[24, 25, 26]} Potentially, someday this procedure could be of benefit for some severely disfigured burn patients.

Eyelid

Eyelid reconstruction has highest priority because the lid functions to protect the cornea. Initiate reconstruction even in the presence of an immature scar. Scar release and subsequent grafting is the procedure of choice. Split-thickness grafts are a better match for the upper eyelid, and the optimal donor site is the contralateral upper lid if uninvolved with injury. Full-thickness grafts better approximate lower lid thickness, and decreased tendency for secondary contraction minimizes chances of postoperative ectropion. Generally, surgeons are recommended to release upper and lower eyelids in separate operative sessions.

Lip and chin region

This region is second in priority. Complications of burns in this region include drooling, microstomia, eating and communication difficulties, lip eversion, and oral hygiene inadequacy. General anesthesia administration in these patients can be difficult and dangerous. This region is not only important but is also one of the most difficult regions to reconstruct adequately. If at all possible, allow scars to fully mature with continuous pressure application so that tissues are soft and supple.

Often, patience yields equivalent or better results than might be expected with surgery. If operative intervention is necessary, thorough scar release with sufficient skin and soft tissue should be added to the lip and chin area, and this frequently requires a multiple-step operation. Full-thickness grafting is the procedure of choice. Reconstruction of very large defects of the lower lip is difficult. Consider cheek advancement flaps, rotation flaps using the residual lip, doublecross-lip flaps, or nasolabial flaps.

Large flaps that cover the chin and upper neck usually obscure the cervicomental angle and add to the appearance of pseudomicrogenia. Free flaps, such as the free radial forearm flap, are also a consideration, but the thickness of the flap should be reduced to cover the defect of the lower lip and chin area. To improve the cervicomental angle the lower border of the flap can be fixed with space of 1 finger-width from the hyoid bone. To form the labiomental sulcus, a space between the epidermis of the flap and muscle of the defective area was adhered. ^[19] The addition of an alloplastic chin implant often improves the contour and provides better chin definition. Many authors place a feeding tube at the time of surgery and forbid eating, drinking, or speaking for a week postoperatively.

These are considered major procedures, and patients must receive long-term postoperative care. A modified dynamic mouth splint to minimize microstomia contractures is an important aspect of continued facial burn treatment. Also, compression therapy, scar massage, contact media, exercise, patient education, and neck splinting are used. The prevention and treatment of microstomia is difficult because of the aggressiveness of the contracting tissues and poor patient compliance. ^[27]

Neck

Neck flexion contractures can result in significant posture alteration and in difficulty eating, communicating, and seeing. As with oral burns, general anesthesia administration in these patients may be difficult and dangerous. Splint the neck in patients suffering burns in the cervical region to prevent contracture and to make subsequent surgical intervention easier. Splints should be worn almost continuously. Refit and reapply splints promptly following each surgical intervention for at least 6 months.

Since correction of neck contractures generally requires multiple interventions, these procedures are usually begun early in the reconstructive plan. They are often complimentary procedures performed in tandem with other procedures.

In general, completely excise and resurface hypertrophic or widely restrictive scars. If less than a third of the neck is involved, local tissue transposition, Z-plasty, or W-plasty may be performed to reorient scars from vertical to transverse. For relatively minor burns involving less than two thirds of the neck, tissue expansion may provide an opportunity to replace all scarred tissue. When more than two thirds of the neck is involved, consider regional flaps, free flaps, and grafts. Skin grafts work well but require longer postoperative splinting and are not as aesthetically pleasing.

Cheek

Treat the burned cheek with a facial-pressure garment to assist in scar maturation. This is unnecessary, however, if the entire aesthetic unit is to be excised and grafted. Other options include tissue expansion of unburned cervical skin and local flaps. Postoperatively, a mask should be worn for 6 months if skin grafts have been applied.

Upper lip

The upper lip actually consists of 3 aesthetic units: the 2 lateral lip elements and the central philtral ridge. Usually, an incision is placed transversely at the root of the nose, allowing the upper lip to fall back into its normal position and maintain fullness. The secondary defect is subsequently skin-grafted. The philtral ridge may be augmented with dermal or cartilage grafts that otherwise might be discarded. Patients agreeable to permanent moustache wear might consider moustache reconstruction. This is performed with a free or islandized scalp flap based on the superficial temporal vessels. Achieving the correct downward-growth orientation of hair follicles is a crucial consideration.

Nose

Nasal reconstruction is of intermediate priority. Airway obstruction may require early intervention with scar release and skin grafting. Cosmetic nose reconstruction is better postponed until scar maturation is complete, but total resurfacing with a skin graft may be performed rather early. Since the nose is the central point of the face, many patients derive significant psychological benefit from satisfactory nasal reconstruction. Nasal reconstruction often restores a sense of humanity to individuals. Alar deformities may be treated with a local turndown flap resurfaced with a full-thickness skin graft or a composite graft from the ear.

Total nasal reconstruction may be performed with a forehead flap; however, many patients reject a forehead flap if the forehead is perceived as the only remaining normal region of the face. In these instances, a dorsalis pedis free flap or a Tagliacozzi tubed pedicled flap may be better alternatives.

Forehead

The forehead may be resurfaced completely as an aesthetic unit with a full-thickness skin graft. Tissue expansion is an alternative for a forehead burned on less than half its area. Exposed bone requires introduction of vascularized tissue (eg, temporoparietal fascial flaps) to accept a skin graft.

Generally, perform scalp reconstruction late in the sequence of events. If extensive bone is exposed early, the entire cranium may be resurfaced with a free flap that subsequently may be skin grafted. Scalp flaps may be used for less extensive injuries. Apply scalp flaps for specific indications and design them carefully, as they often leave donor sites as large as the covered defect. Temporoparietal fascial flaps may also be used as a vascularized surface for skin grafting, as with forehead defects. Punch grafts or hair transplants generally do not survive in previously burned or grafted skin that has a less-than-optimal blood supply. Tissue expansion is optimal if enough unburned hair-bearing skin remains. Advantages of tissue expansion include (1) no donor site creation; (2) donor skin of very similar color, thickness, and texture; and (3) high hair follicle survival rate. Patients who reject these procedures may wear hairpieces or wigs.

Eyebrow reconstruction may proceed with strips of hair-bearing scalp transplanted as free grafts. Delicately handle and minimally defat these grafts because significant follicle loss may accompany this technique. Another option for bushier eyebrows is transference of a hair-bearing scalp segment as an island flap based on the superficial temporal vessels, as in upper-lip moustache reconstruction.

Ear

Ear reconstruction is generally performed last because the first choice for reconstruction uses available local tissue that should be allowed to achieve mature scarring. Indications for early intervention include cartilage exposure, in which case a turnover temporoparietal fascial flap may be used as a vascularized surface over which to apply a full-thickness skin graft.

Reconstructive options include local skin and fascial flaps with/without tissue expansion, ipsilateral axial temporoparietal fascial flap, contralateral temporoparietal, or an ipsilateral random fascial flaps. If the entire skin of the temporoauriculomastoid region is lost or badly scared with poor axial vascularity, a bilobed cervical flap or fascial free flap is an option. ^[28] Rib cartilages are harvested from the right side and sculptured to create an ear frame. Another solution is the osseointegrated auricular prostheses, but it has a high cost and risk of potential complications over the long term.

After wound closure, scar hypertrophy may begin within 3 weeks. Scar hypertrophy is most exuberant over the next 3 months and is characterized by raised, red, itchy, tight scars. These scars then slowly regress during the following 12-24 months. At completion of this process, a mature scar remains that is characteristically white, soft, and flat. If possible, depending on clinical condition and patient insistence, exercise an observation protocol and patience until scars mature.

Postoperative care includes the continuous use of pressure garments or masks fitted early after injury. Regularly reassess, remold, and, as necessary, replace these garments to ensure continuous uniform pressure over the entire scarred area. Silicone pads are also sometimes used. No pressure should be placed on the auricle. These pressure devices lead to softer, less exuberant scars. Application of splints (Hartford or Larson device) to oral commissures and the neck may help prevent contracture development. Appropriate early measures may render subsequent procedures unnecessary or less difficult. Triamcinolone may be injected if hypertrophic scarring begins to develop.

The patient should begin scar massage as soon as wounds heal. Instruction in use of camouflage makeup may make a substantial impact on the lifestyle of these patients and their willingness to appear in public. Finally, instruct patients to wear moisturizing sunscreen and avoid direct sun exposure for the first 12 months following burn scar healing and skin grafting. These precautions avoid potential hyperpigmentation complications.

A prospective, observational, controlled study by Beck et al found that out of a cohort of patients with facial burns, 29% experienced an acute, post-burn occurrence of hyposmia. In contrast, hyposmia was found in just 9% of the control group. Of those patients with hyposmia who completed the study, the majority regained their normal sense of smell by 1 year subsequent to the burn injury. Hyposmia was especially common in patients who suffered inhalation trauma or whose burn occupied a larger percentage of their total body surface area. ^[29]

A prospective study by Ryan et al found that in burn patients and persons without burns, aged 19-30 years, the overall difference in recovery outcomes between burn survivors with facial burns and those without lessened over time. Using the Young Adult Burn Outcome Questionnaire (YABOQ) to track patients over a 36-month period, the investigators reported that although the perceived appearance score started out lower in the facial burn group compared with patients with nonfacial burns, the variation subsequently lessened. However, the investigators reported religion scores to be persistently higher and emotion and sexual function scores to be persistently lower in patients with facial burns. Moreover, the score for social function limited by appearance, while similar at the outset between the study’s subjects, diminished over time in patients with facial burns. ^[30]