- Email: [email protected]
Oral commissure burns in children
Operative Techniques in Otolaryngology (2015) 26, 136–142
Oral commissure burns in children Frank G. Garritano, MD, Michele M. Carr, DDS, MD, PhD From the Division of Otolaryngology-Head and Neck Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania KEYWORDS Oral commisure; pediatric; burns; lip reconstruction
Pediatric oral commissure burns present a therapeutic and reconstructive challenge. Although these injuries are fairly common in young children, there exists some controversy on the appropriate timing and nature of the repair that should be performed. Some authors advocate early surgical intervention, whereas others advocate a far more conservative approach that uses prolonged splinting techniques in the hope of avoiding the need for reconstructive surgery. In the event that reconstructive surgery becomes necessary, there exists a wide range of reconstructive techniques that are described in the literature, from simple excision and skin grafting to complex local flap reconstruction using adjacent or distant tissue. In this article, we present an overview of the nature of pediatric oral commissure burns, identify special concerns in pediatric burn patient, discuss the potential role for oral commissure splinting, and finally review a number of different surgical reconstructive techniques that have been proposed in the literature. r 2015 Elsevier Inc. All rights reserved.
Introduction and epidemiology The number of burn injuries in the United States is estimated to be between 500,000 and 2 million per year.1-3 Up to 400,000 children are treated annually for burn injuries in the United States, and burns are the third most common cause of death among children aged 0-14 years.4,5 It is important to keep in mind the possibility of nonaccidental injury in these cases, as up to 20% of pediatric burn admissions involve child abuse or neglect, particularly those cases involving scalding injuries.3,6,7 It is noteworthy that boys are more commonly involved in burn cases than girls are, in some studies in a ratio as high as 2:1, and that children diagnosed with attention-deficit hyperactivity disorder also are at a higher risk.3,8,9 Specifically, electrical burns tend to occur mostly in children aged between 0 and 4 years and tend to Address reprint requests and correspondence: Frank Garritano, MD, H091, 500 University Dr, Hershey, PA 17033. E-mail address: [email protected] http://dx.doi.org/10.1016/j.otot.2015.06.007 1043-1810/r 2015 Elsevier Inc. All rights reserved.
disproportionately involve the lips, mouth, or tongue.10 In a series of all pediatric patients presenting with electrical burns, the mouth was the most common site of injury, nearly all patients were younger than 4 years (93%), and most patients were younger than 2 years at the time of injury (65%).10 The most common mechanism of injury involves children biting into an electrical cord, touching the male ends of a live but improperly connected cord, or sucking on the female end of an extension cord that is plugged into the wall.11 There are 2 mechanisms of injury that are frequently described in relation to electrical burns: the arc burn and the contact burn.10,11 A contact burn, which is less common around the mouth, typically requires 2 points of contact, such that the current flows from the electrical source, pass through a part of the body, and exit through the ground via the path of least resistance. An arc burn, which is the most common type of injury around the mouth, results from the electrolyte-rich saliva completing a circuit between 2 conductive wires, which initiates an arc or a flash, and this has been reported to generate temperatures as high as 3,0001C.
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The low electrical resistance of the mucous membranes makes them particularly susceptible to severe injury via this mechanism. The most common site of involvement in the mouth is the oral commissure and the upper and lower lips adjacent to the commissure.11 Although these injuries are rare, involvement of the oral commissure is common, and knowledge of the proper treatment is important to achieve acceptable functional and cosmetic outcomes.
Special concerns in pediatric burn patients Caring for pediatric patients with facial burns requires a comprehensive and multidisciplinary approach to management, and the American College of Surgeons therefore recommends that all patients with facial burns be triaged to American Burn Association–certified burn centers.12 When initially assessing pediatric facial burn patients, it is important to keep in mind the ABCs—airway, breathing, and circulation. Evaluation should be done for any physical evidence of airway burns, which can include charring of the mouth or lips, singeing of nasal hairs or eyebrows, dark and carbon-stained mucus, wheezing, changes in voice, difficulty in breathing, or coughing. In such cases, definitive airway management in the form of endotracheal intubation may be advisable given the possibility for airway edema that can develop in a delayed fashion after the injury. Particularly in children, it is important to keep in mind circulatory support. Major burn injuries are typically accompanied by massive fluid loss, and although children may initially compensate quite well for this, there exists a greater potential for precipitous and rapid circulatory collapse than what exists in adults. The Parkland formula and the palmar method allow for quick calculation of the amount of resuscitation fluid that is estimated to be required over the first 24 hours after injury. Verification of tetanus prophylaxis should be performed, and booster vaccinations can be administered if indicated. Management of facial burns in pediatric patients is an area particularly fraught with psychological, developmental, functional, and esthetic concerns. The facial form contains various complex concave and convex surfaces arranged in juxtaposition, structures that are lacking in internal support, and multiple dynamic subunits that are responsible for sight, speech, and oral consumption. Therefore, treatment of these injuries requires a comprehensive, multidisciplinary approach that attends to the preservation of function and esthetics while also considering the psychological and developmental concerns unique to the pediatric population.
Oral commissure burns There have been several classification systems put forth to describe the degree of tissue damage in pediatric patients with oral commissure burns; however, none has gained widespread acceptance. One schema created by Ortiz-Monasterio
137 and Factor classified injuries according to the percentage involvement of the upper or the lower lip; however, a more recent classification system proposed by Al-Qattan et al8 organizes oral commissure burns according to depth and extent of the injury.13 On initial presentation, burn injuries to the oral commissure typically appear gray to white with evidence of charring. The wounds are frequently painless and bloodless because of the nature of a high-temperature thermal injury. The lower lip and oral commissure are involved more frequently than the upper lip is, and patients may present initially with poor salivary control. Importantly, it is very difficult to assess the true margins of injury at initial presentation, and the actual area of involvement may be more than initially believed. As the burn injury evolves, the patient begins to develop a rim of erythema and edema in the surrounding tissue, and after the first 24 hours, an obvious margin indicating the area of tissue necrosis usually forms because of thrombosis of the blood vessels in the affected area. Eschar and coagulative necrosis develop as the wound heals, with eventual slough of the eschar in 1-4 weeks. The developing scar has a tendency to contract as the soft tissue remodels over time. Although bleeding at initial presentation is uncommon, there appears to be a delayed risk of bleeding from the labial artery that can occur between 1 and 2 weeks following the injury in up to 25% of cases.14 When treating facial burns, some authors outlined what they consider to be the 5 reconstructive goals of treatment: an undistracted, “normal” look at conversational distance; facial balance and symmetry; distinct esthetic units fused by inconspicuous scars; a doughy skin texture appropriate for corrective makeup; and a dynamic facial expression.15 Although this pertains to all facial burns and is not specific to oral commissure burns per se, it does provide us with some important considerations to keep in mind when treating these injuries.
Treatment of oral commissure burns The timing and the appropriate treatment for burn injuries to the oral commissure, lips, and tongue continues to be controversial. A wide variety of treatment strategies and surgical techniques performed at varying intervals from the time of injury have been studied and proposed without the development of any widespread consensus. In general and to more easily discuss the available treatment options, we can categorize interventions based on the time point at which they are performed: early intervention, which occurs within a few days of the injury; intermediate intervention, which occurs at the time that necrosis can be distinguished from normal tissue (typically 1-4 weeks); and delayed intervention, where repair is begun after all the tissues have healed (after several months).11 The choice of treatment strategy can vary depending on the length of time elapsed since the burn injury, the degree and extent of the injury, and the individual surgeon's preferences.11
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Early and intermediate intervention Advocates of early intervention believe that the best results in treating oral commissure burns can be obtained with early excision of damaged tissue. These authors report that this approach results in faster healing, a shorter hospital stay, fewer total surgical procedures, and overall better final results. Some authors report promising results initially, whereas others report disappointing late functional and esthetic results.16-20 It is also important to consider that early excision of damaged tissues can cause tightening of the soft tissue envelope over the mandible and subsequently impair bony mandibular growth and development.13,21,22 A major disadvantage to this approach is that the extent of tissue damage and necrosis may not be initially evident, and attempts to estimate the area of involvement may result in resection of otherwise viable tissues. Some authors prefer an intermediate course of intervention, favoring the excision of damaged tissue and eschar as soon as the extent of necrosis is clear and can be differentiated from the surrounding healthy tissues, typically 1-4 weeks after the initial injury. They report that this approach minimizes scarring, decreases the number of bleeding episodes from the labial artery by avoiding the inevitable slough of the eschar, avoids secondary infections as the wounds heal, and allows for better reconstructive results.13,23-25
Conservative or delayed treatment Advocates for conservative or delayed treatment point out that it can be difficult to assess the extent of injury immediately and that surgical intervention before scar maturation may increase the risk of hypertrophic scar formation.11,26-28 They point out that after maturation of the scar, the extent of damage is more apparent, that functional and esthetic deficits would have more definitively declared themselves, and that reconstruction is ultimately more successful.11,26-28 Authors variably advocate for the use of oral or topical antibiotic prophylaxis with or without vigorous scar massage with vitamin E or steroid-based creams.11 Although there remains significant controversy, it appears that conservative treatment is favored by many authors.10,11,26
Oral commissure splinting The organization of scar tissue in the early phases of maturation tends toward shortening and wound contracture, unless influenced by opposing forces.29,30The goal of splinting the oral commissure is to provide a countering force against the tendency for wound contracture, with the goal of reducing scarring, maintaining function, and reducing the need for reconstructive surgery. The use of oral commissure splints was described in the literature starting between 1972 and 1976.31,32 There are many
different devices that have been used for this purpose, including both intraoral and extraoral devices, as well as devices where the stretching force is applied vertically across the oral commissure, horizontally, or circumorally.33 In general, use of the splinting device begins when most of the facial edema has resolved and patients are able to tolerate wearing the device with minimal discomfort. The splinting device is worn at all times, except for when the patient is eating or performing oral care. As the process of scar maturation and reorganization can continue for up to 12 years, the device is worn for a prolonged period of at least several months. Patient and parental compliance is crucial for success.20 Their use has remained controversial, with some authors preferring the use of early splinting devices and others preferring that they never be used.11,26 Although evidence for their use is limited, splints have been demonstrated to be successful in several retrospective studies.8,32 In a study, the authors examined 85 patients with oral commissure burns treated with oral commissure splints between 1974 and 1986.8 They found that before the introduction of routine splinting, 8 of 95 patients (8.4%) required surgery to correct microstomia, whereas after the introduction of routine splinting in 1974, only 3 of 85 patients (3.5%) required surgery. The authors found that of the 3 patients requiring surgery, 2 were noncompliant with the splint therapy, meaning only 1 patient of the 83 who underwent splinting ultimately required a surgical intervention for the correction of microstomia, which is a statistically significant difference (P o 0.03).8 A second retrospective study examined 42 patients with oral commissure burns treated between 1968 and 1986 either with or without oral commissure splinting.32 Of them, 20 underwent early splinting, whereas 22 did not undergo splinting therapy. They found that 7 of the patients who underwent splinting ultimately required surgical commissuroplasty, whereas 19 of the patients who did not undergo splinting ultimately required surgery (P o 0.05).32 In addition, all 7 patients in the splinting group who ultimately required surgery wore their splints for less than 4 months, whereas the remaining 13 patients in the splinting group who did not require surgery wore their splints on average for more than 4 months, thus suggesting that for splinting to be effective, it must be performed for a prolonged period.32 Taken together, the data, although limited and retrospective, do suggest that oral commissure splinting is a useful treatment for pediatric patients with oral commissure burns and may reduce the need for future surgical commissuroplasty.8,32
Oral commissure reconstruction The goal of oral commissure reconstruction should attempt to restore normal structures to their normal positions, and recreate a thin, mobile lip segment that moves dynamically and symmetrically with facial expression.34 The treatment used to achieve these goals has changed significantly over the years. In the late 1920s, surgeons advocated for
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Figure 1 An example of a left-sided oral commissure injury (A). A lip mucosal advancement flap is performed by first excising the oral commissure scar (B) followed by advancement of the upper and lower lip mucosa into the defect.
resection of the mature eschar followed by careful skin grafting to recreate the oral commissure. Unfortunately, this often failed to prevent the development of subsequent oral commissure contraction; hence, since that time, a number of
other techniques have been advocated by a number of different authors. Some surgeons have advocated the use of a lip mucosal advancement flap (Figure 1).35 The way this technique was
Figure 2 An example of a modification of the lip mucosal advancement flap closure. In this technique, the scarring at the oral commissure is left intact (A) and a recipient site is designed lateral to the existing commissure (B). Upper and lower lip mucosal flaps are then advanced into the defect lateral to the native oral commissure.
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Figure 3 An example of cheek mucosal advancement flap reconstruction of an oral commissure defect (A). The existing oral commissure scar is excised (B) and a pedicled cheek mucosal flap is designed (C) and advanced into the defect (D) where it is sutured in place (E and F).
initially described, the scarring around the oral commissure is excised, and banner flaps using the existing vermilion are advanced into a lateral position that approximates the native position of the oral commissure. An advantage is that this technique, because the vermillion and the mucosa are being advanced, tends to give a more natural appearance than simple excision and skin grafting does.35 A significant downside to this method is that it can result in diminished mouth opening on the affected side.11 A modification of this technique involves leaving all the scar tissue intact, and fashioning advancement flaps of existing vermilion that are advanced into a more lateral position (Figure 2).36 Another technique that has been used to reconstruct the scarred oral commissure involves the use of cheek mucosal advancement flaps.11 Using this technique, a new oral commissure is planned at a point 2 mm lateral to the native commissure to correct for expected postoperative scar contracture. An incision is then performed through the skin and muscle to completely the scarred tissue while preserving the native, undamaged mucosal tissue. Mucosal flaps from the cheek are then advanced along with the remaining vermilion to close the defect (Figure 3). The authors note that these cheek mucosal flaps tend to be more reliable and successful when compared with techniques in which only the vermilion is advanced into the defect; however, a
downside to this technique is that it can also result in shortening of the oral aperture on the affected side.11 Another technique that builds on the use of lip or cheek mucosal advancement flaps has also been described in a small series of patients.35 Using this technique, the oral commissure scar is partially excised, and buccal mucosa is advanced into the apex of the commissure (Figure 4). Splitthickness skin grafts are then taken from the adjacent lip tissue and are used to cover the existing raw surface of the injured vermilion. A full-thickness graft is then taken from the preauricular skin to reconstruct the skin immediately lateral to the oral commissure. This helps to blend the lateral aspect of the scar into the surrounding cheek. This technique has a number of distinct advantages. Firstly, the cosmetic deformity seen after oral commissure burns and reconstruction frequently extends onto the skin lateral to the oral commissure, an area that is not directly addressed with the use of vermilion or cheek advancement flaps.36 In addition, simple advancement of the adjacent vermilion into the wound bed tends to result in a “bunching” effect that adds some bulk to the oral commissure and results in a poor cosmetic match at the mucocutaneous junction.36 The use of a ventral tongue flap has also been described in small case series for the reconstruction of electrical burns of the oral commissure.34 An advantage of using a tongue
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141
Figure 4 An example of an alternative method of oral commissure reconstruction. The oral commissure scar is partially excised (A) and a buccal mucosal advancement flap is advanced into the apex of the commissure (B). Vermillion grafts are taken from the contralateral lip and used to reconstruct the upper and lower lip in the region of the oral commissure (C) followed by a full-thickness skin graft placed lateral to the commissure (D) to reconstruct the adjacent injured skin.
flap is that the flap can include muscle to replace missing orbicularis oris while also providing increased vascularity and durability. In addition, a large volume of tissue can be mobilized in this fashion to repair extensive defects that may not be amenable to closure with other techniques.34 Although the cosmetic match between tongue tissue and the vermilion mucosa is not ideal, the authors believe it to be a better match than buccal mucosa.34 The flap is designed as an anteriorly based tongue flap, taking care to exclude the filiform papillae present on the dorsal surface of the tongue. The donor site is closed primarily, and the tip of the tongue flap is advanced to the medial edge of the lower lip defect (Figure 5). The remainder of the flap is used to reconstruct the lateral lower lip, and the flap is typically divided at 2 weeks.
Conclusions Oral commissure burns in the pediatric population remain a reconstructive challenge. In most circumstances, a delayed approach to repair is used, giving time for the initial wound to declare itself. The use of oral commissure splinting, although challenging in practice, has been demonstrated to help prevent the need for surgical reconstruction of the oral commissure in the future. If surgical reconstruction is necessary, the goals include maintaining both normal function and cosmesis. A number of different techniques have been advocated for reconstruction of the oral commissure, and each has particular advantages and drawbacks that may make it more or less well suited for a particular injury.
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Figure 5 An example of a pedicled ventral tongue flap used to reconstruct the oral commissure.
References 1. McCaig L, Nawar E: National Hospital Ambulatory Medical Care Survey: 2004 Emergency department summary. Advance Data From Vital and Health Statistics of the National Center for Health Statistics, 2006 2. Hing E, Cherry D, Woodwell D: National Ambulatory Medical Care Survey: 2004 Summary. Advance Data From Vital and Health Statistics of the National Center for Health Statistics, 2006 3. Herndon D, Rutan R, Rutan T: Management of the pediatric patient with burns. J Burn Care Rehabil 14(3):3-8, 1993 4. Hall M, Owings M: Hospitalizations for injury: United States, 1996. NCHS—Vital and Health Statistics of the Centers for Disease Control and Prevention 218(4), 2000 5. System N: Deaths: Final data for 1997. Centers for Disease Control and Prevention 47(1), 1999 6. Ruth G, Smith S, Bronson M, et al: Outcomes related to burn-related child abuse: A case series. J Burn Care Rehabil 24:318, 2003 7. Renz B, Sherman R: Child abuse by scalding. J Med Assoc Ga 81: 574, 1992 8. Al-Qattan M, Gillett D, Thomson H: Electrical burns to the oral commissure: Does splinting obviate the need for commissuroplasty? Burns 22(7):555-556, 1996 9. Celik A, Ergun O, Ozok G: Pediatric electrical injuries: A review of 28 consecutive patients. J Pediatr Surg 39:1233, 2004 10. Vorhies J: Electrical burns of the oral commissure. Angle Orthod 57(1): 2-17, 1987
11. Canady J, Thompson S, Bardacj J: Oral commissure burns in children. Plast Reconstr Surg 97(4):738-744, 1996 12. American Burn Association/American College of Surgeons: Guidelines for the operation of burn centers. J Burn Care Res 28:134, 2007 13. Ortiz-Monasterio F, Factor R: Early definitive treatment of electrical burns of the mouth. Plast Reconstr Surg 65:169-176, 1980 14. Thompson H, Juckes A, Farmer A: Electrical burns to the mouth in children. Am J Surg 88(884):466-477, 1954 15. Rose EH: Aesthetic restoration of the severely disfigured face in burn victims: A comprehensive strategy. Plast Reconstr Surg 111(744): 1573-1585, 1995 16. Zarem H, Greer D: Tongue flap for reconstruction of the lips after electrical burns. Plast Reconstr Surg 53:310, 1974 17. Orgel M, Brown H, Woolhouse F: Electrical burns of the mouth in children. J Trauma 15(285):285-289, 1976 18. De la Plaza R, Quetglas A, Rodriguez E: Treatment of electrical burns of the mouth. Burns 10(49), 1983 19. Edlich R, Nichter I, Morgan R, et al: Burns of the head and neck. Otolaryngol Clin North Am 17(361):361-388, 1984 20. Leake J, Curtin J: Electric burns of the mouth in children. Clin Plast Surg 11:669, 1984 21. Gifford G, Marty A, MacCollum D: The management of electrical burns in children. Pediatrics 47(113):113-119, 1971 22. Hartford CE, Kealy GP, Lavelle WE, et al: An appliance to prevent and treat microstomia from burns. J Trauma 15:356, 1975 23. Kazanjian V, Roopenian A: The treatment of lip deformities resulting from electrical burns. Plast Reconstr Surg 35(466):884-890, 1965 24. Fleury A: Electrical burns of the lips: A modified plan of treatment. Am Surg 25:328-331, 1959 25. Lawson W: Management of soft tissue injuries of the face. Otolaryngol Clin North Am 15:35, 1982 26. Egeland B, More S, Buchman S, et al: Management of difficult pediatric facial burns: Reconstruction of burn-related lower eyelid ectropion and perioral contractures. J Craniofac Surg 19(4):960-969, 2008 27. Pitanguy I, de Lima P, Muller P, et al: Electric burns of the lip. Compend Contin Educ Dent 10(30):30-34, 1989 28. Pensler J, Rosenthal A: Reconstruction of the oral commissure after an electrical burn. J Burn Care Rehabil 11:50, 1990 29. Larson D, Abston S, Evans D, et al: Techniques for decreasing scar formation and contractures in the burned patient. J Trauma 11:807-823, 1971 30. Morgan R, Nichter L, Haines P, et al: Management of head and neck burns. J Burn Care Rehabil 6:20-38, 1985 31. Colcleugh R, Ryan J: Splinting electrical burns of the mouth in children. Plast Reconstr Surg 58:239-241, 1976 32. Heinle J, Kealey G, Cram A, et al: The microstomia prevention appliance: 14 years of clinical experience. J Burn Care Rehabil 9(1): 90-91, 1988 33. Dougherty M, Warden G: A thirty year review of oral appliances used to manage microstomia, 1972-2002. J Burn Care Rehabil 24(6):418431, 2003 34. Donelan MB: Reconstruction of electrical burns of the oral commissure with a ventral tongue flap. Plast Reconstr Surg 95(7):1155-1164, 1995 35. Anderson R, Kurtay M: Reconstruction of the corner of the mouth. Plast Reconstr Surg 47(5):463-464, 1971 36. Vecchione TR: An approach to the late effects of oral commissure injuries. Aesthetic Plast Surg 10(2):105-110, 1986
Oral commissure burns in children Frank G. Garritano, MD, Michele M. Carr, DDS, MD, PhD From the Division of Otolaryngology-Head and Neck Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania KEYWORDS Oral commisure; pediatric; burns; lip reconstruction
Pediatric oral commissure burns present a therapeutic and reconstructive challenge. Although these injuries are fairly common in young children, there exists some controversy on the appropriate timing and nature of the repair that should be performed. Some authors advocate early surgical intervention, whereas others advocate a far more conservative approach that uses prolonged splinting techniques in the hope of avoiding the need for reconstructive surgery. In the event that reconstructive surgery becomes necessary, there exists a wide range of reconstructive techniques that are described in the literature, from simple excision and skin grafting to complex local flap reconstruction using adjacent or distant tissue. In this article, we present an overview of the nature of pediatric oral commissure burns, identify special concerns in pediatric burn patient, discuss the potential role for oral commissure splinting, and finally review a number of different surgical reconstructive techniques that have been proposed in the literature. r 2015 Elsevier Inc. All rights reserved.
Introduction and epidemiology The number of burn injuries in the United States is estimated to be between 500,000 and 2 million per year.1-3 Up to 400,000 children are treated annually for burn injuries in the United States, and burns are the third most common cause of death among children aged 0-14 years.4,5 It is important to keep in mind the possibility of nonaccidental injury in these cases, as up to 20% of pediatric burn admissions involve child abuse or neglect, particularly those cases involving scalding injuries.3,6,7 It is noteworthy that boys are more commonly involved in burn cases than girls are, in some studies in a ratio as high as 2:1, and that children diagnosed with attention-deficit hyperactivity disorder also are at a higher risk.3,8,9 Specifically, electrical burns tend to occur mostly in children aged between 0 and 4 years and tend to Address reprint requests and correspondence: Frank Garritano, MD, H091, 500 University Dr, Hershey, PA 17033. E-mail address: [email protected] http://dx.doi.org/10.1016/j.otot.2015.06.007 1043-1810/r 2015 Elsevier Inc. All rights reserved.
disproportionately involve the lips, mouth, or tongue.10 In a series of all pediatric patients presenting with electrical burns, the mouth was the most common site of injury, nearly all patients were younger than 4 years (93%), and most patients were younger than 2 years at the time of injury (65%).10 The most common mechanism of injury involves children biting into an electrical cord, touching the male ends of a live but improperly connected cord, or sucking on the female end of an extension cord that is plugged into the wall.11 There are 2 mechanisms of injury that are frequently described in relation to electrical burns: the arc burn and the contact burn.10,11 A contact burn, which is less common around the mouth, typically requires 2 points of contact, such that the current flows from the electrical source, pass through a part of the body, and exit through the ground via the path of least resistance. An arc burn, which is the most common type of injury around the mouth, results from the electrolyte-rich saliva completing a circuit between 2 conductive wires, which initiates an arc or a flash, and this has been reported to generate temperatures as high as 3,0001C.
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The low electrical resistance of the mucous membranes makes them particularly susceptible to severe injury via this mechanism. The most common site of involvement in the mouth is the oral commissure and the upper and lower lips adjacent to the commissure.11 Although these injuries are rare, involvement of the oral commissure is common, and knowledge of the proper treatment is important to achieve acceptable functional and cosmetic outcomes.
Special concerns in pediatric burn patients Caring for pediatric patients with facial burns requires a comprehensive and multidisciplinary approach to management, and the American College of Surgeons therefore recommends that all patients with facial burns be triaged to American Burn Association–certified burn centers.12 When initially assessing pediatric facial burn patients, it is important to keep in mind the ABCs—airway, breathing, and circulation. Evaluation should be done for any physical evidence of airway burns, which can include charring of the mouth or lips, singeing of nasal hairs or eyebrows, dark and carbon-stained mucus, wheezing, changes in voice, difficulty in breathing, or coughing. In such cases, definitive airway management in the form of endotracheal intubation may be advisable given the possibility for airway edema that can develop in a delayed fashion after the injury. Particularly in children, it is important to keep in mind circulatory support. Major burn injuries are typically accompanied by massive fluid loss, and although children may initially compensate quite well for this, there exists a greater potential for precipitous and rapid circulatory collapse than what exists in adults. The Parkland formula and the palmar method allow for quick calculation of the amount of resuscitation fluid that is estimated to be required over the first 24 hours after injury. Verification of tetanus prophylaxis should be performed, and booster vaccinations can be administered if indicated. Management of facial burns in pediatric patients is an area particularly fraught with psychological, developmental, functional, and esthetic concerns. The facial form contains various complex concave and convex surfaces arranged in juxtaposition, structures that are lacking in internal support, and multiple dynamic subunits that are responsible for sight, speech, and oral consumption. Therefore, treatment of these injuries requires a comprehensive, multidisciplinary approach that attends to the preservation of function and esthetics while also considering the psychological and developmental concerns unique to the pediatric population.
Oral commissure burns There have been several classification systems put forth to describe the degree of tissue damage in pediatric patients with oral commissure burns; however, none has gained widespread acceptance. One schema created by Ortiz-Monasterio
137 and Factor classified injuries according to the percentage involvement of the upper or the lower lip; however, a more recent classification system proposed by Al-Qattan et al8 organizes oral commissure burns according to depth and extent of the injury.13 On initial presentation, burn injuries to the oral commissure typically appear gray to white with evidence of charring. The wounds are frequently painless and bloodless because of the nature of a high-temperature thermal injury. The lower lip and oral commissure are involved more frequently than the upper lip is, and patients may present initially with poor salivary control. Importantly, it is very difficult to assess the true margins of injury at initial presentation, and the actual area of involvement may be more than initially believed. As the burn injury evolves, the patient begins to develop a rim of erythema and edema in the surrounding tissue, and after the first 24 hours, an obvious margin indicating the area of tissue necrosis usually forms because of thrombosis of the blood vessels in the affected area. Eschar and coagulative necrosis develop as the wound heals, with eventual slough of the eschar in 1-4 weeks. The developing scar has a tendency to contract as the soft tissue remodels over time. Although bleeding at initial presentation is uncommon, there appears to be a delayed risk of bleeding from the labial artery that can occur between 1 and 2 weeks following the injury in up to 25% of cases.14 When treating facial burns, some authors outlined what they consider to be the 5 reconstructive goals of treatment: an undistracted, “normal” look at conversational distance; facial balance and symmetry; distinct esthetic units fused by inconspicuous scars; a doughy skin texture appropriate for corrective makeup; and a dynamic facial expression.15 Although this pertains to all facial burns and is not specific to oral commissure burns per se, it does provide us with some important considerations to keep in mind when treating these injuries.
Treatment of oral commissure burns The timing and the appropriate treatment for burn injuries to the oral commissure, lips, and tongue continues to be controversial. A wide variety of treatment strategies and surgical techniques performed at varying intervals from the time of injury have been studied and proposed without the development of any widespread consensus. In general and to more easily discuss the available treatment options, we can categorize interventions based on the time point at which they are performed: early intervention, which occurs within a few days of the injury; intermediate intervention, which occurs at the time that necrosis can be distinguished from normal tissue (typically 1-4 weeks); and delayed intervention, where repair is begun after all the tissues have healed (after several months).11 The choice of treatment strategy can vary depending on the length of time elapsed since the burn injury, the degree and extent of the injury, and the individual surgeon's preferences.11
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Early and intermediate intervention Advocates of early intervention believe that the best results in treating oral commissure burns can be obtained with early excision of damaged tissue. These authors report that this approach results in faster healing, a shorter hospital stay, fewer total surgical procedures, and overall better final results. Some authors report promising results initially, whereas others report disappointing late functional and esthetic results.16-20 It is also important to consider that early excision of damaged tissues can cause tightening of the soft tissue envelope over the mandible and subsequently impair bony mandibular growth and development.13,21,22 A major disadvantage to this approach is that the extent of tissue damage and necrosis may not be initially evident, and attempts to estimate the area of involvement may result in resection of otherwise viable tissues. Some authors prefer an intermediate course of intervention, favoring the excision of damaged tissue and eschar as soon as the extent of necrosis is clear and can be differentiated from the surrounding healthy tissues, typically 1-4 weeks after the initial injury. They report that this approach minimizes scarring, decreases the number of bleeding episodes from the labial artery by avoiding the inevitable slough of the eschar, avoids secondary infections as the wounds heal, and allows for better reconstructive results.13,23-25
Conservative or delayed treatment Advocates for conservative or delayed treatment point out that it can be difficult to assess the extent of injury immediately and that surgical intervention before scar maturation may increase the risk of hypertrophic scar formation.11,26-28 They point out that after maturation of the scar, the extent of damage is more apparent, that functional and esthetic deficits would have more definitively declared themselves, and that reconstruction is ultimately more successful.11,26-28 Authors variably advocate for the use of oral or topical antibiotic prophylaxis with or without vigorous scar massage with vitamin E or steroid-based creams.11 Although there remains significant controversy, it appears that conservative treatment is favored by many authors.10,11,26
Oral commissure splinting The organization of scar tissue in the early phases of maturation tends toward shortening and wound contracture, unless influenced by opposing forces.29,30The goal of splinting the oral commissure is to provide a countering force against the tendency for wound contracture, with the goal of reducing scarring, maintaining function, and reducing the need for reconstructive surgery. The use of oral commissure splints was described in the literature starting between 1972 and 1976.31,32 There are many
different devices that have been used for this purpose, including both intraoral and extraoral devices, as well as devices where the stretching force is applied vertically across the oral commissure, horizontally, or circumorally.33 In general, use of the splinting device begins when most of the facial edema has resolved and patients are able to tolerate wearing the device with minimal discomfort. The splinting device is worn at all times, except for when the patient is eating or performing oral care. As the process of scar maturation and reorganization can continue for up to 12 years, the device is worn for a prolonged period of at least several months. Patient and parental compliance is crucial for success.20 Their use has remained controversial, with some authors preferring the use of early splinting devices and others preferring that they never be used.11,26 Although evidence for their use is limited, splints have been demonstrated to be successful in several retrospective studies.8,32 In a study, the authors examined 85 patients with oral commissure burns treated with oral commissure splints between 1974 and 1986.8 They found that before the introduction of routine splinting, 8 of 95 patients (8.4%) required surgery to correct microstomia, whereas after the introduction of routine splinting in 1974, only 3 of 85 patients (3.5%) required surgery. The authors found that of the 3 patients requiring surgery, 2 were noncompliant with the splint therapy, meaning only 1 patient of the 83 who underwent splinting ultimately required a surgical intervention for the correction of microstomia, which is a statistically significant difference (P o 0.03).8 A second retrospective study examined 42 patients with oral commissure burns treated between 1968 and 1986 either with or without oral commissure splinting.32 Of them, 20 underwent early splinting, whereas 22 did not undergo splinting therapy. They found that 7 of the patients who underwent splinting ultimately required surgical commissuroplasty, whereas 19 of the patients who did not undergo splinting ultimately required surgery (P o 0.05).32 In addition, all 7 patients in the splinting group who ultimately required surgery wore their splints for less than 4 months, whereas the remaining 13 patients in the splinting group who did not require surgery wore their splints on average for more than 4 months, thus suggesting that for splinting to be effective, it must be performed for a prolonged period.32 Taken together, the data, although limited and retrospective, do suggest that oral commissure splinting is a useful treatment for pediatric patients with oral commissure burns and may reduce the need for future surgical commissuroplasty.8,32
Oral commissure reconstruction The goal of oral commissure reconstruction should attempt to restore normal structures to their normal positions, and recreate a thin, mobile lip segment that moves dynamically and symmetrically with facial expression.34 The treatment used to achieve these goals has changed significantly over the years. In the late 1920s, surgeons advocated for
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Figure 1 An example of a left-sided oral commissure injury (A). A lip mucosal advancement flap is performed by first excising the oral commissure scar (B) followed by advancement of the upper and lower lip mucosa into the defect.
resection of the mature eschar followed by careful skin grafting to recreate the oral commissure. Unfortunately, this often failed to prevent the development of subsequent oral commissure contraction; hence, since that time, a number of
other techniques have been advocated by a number of different authors. Some surgeons have advocated the use of a lip mucosal advancement flap (Figure 1).35 The way this technique was
Figure 2 An example of a modification of the lip mucosal advancement flap closure. In this technique, the scarring at the oral commissure is left intact (A) and a recipient site is designed lateral to the existing commissure (B). Upper and lower lip mucosal flaps are then advanced into the defect lateral to the native oral commissure.
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Figure 3 An example of cheek mucosal advancement flap reconstruction of an oral commissure defect (A). The existing oral commissure scar is excised (B) and a pedicled cheek mucosal flap is designed (C) and advanced into the defect (D) where it is sutured in place (E and F).
initially described, the scarring around the oral commissure is excised, and banner flaps using the existing vermilion are advanced into a lateral position that approximates the native position of the oral commissure. An advantage is that this technique, because the vermillion and the mucosa are being advanced, tends to give a more natural appearance than simple excision and skin grafting does.35 A significant downside to this method is that it can result in diminished mouth opening on the affected side.11 A modification of this technique involves leaving all the scar tissue intact, and fashioning advancement flaps of existing vermilion that are advanced into a more lateral position (Figure 2).36 Another technique that has been used to reconstruct the scarred oral commissure involves the use of cheek mucosal advancement flaps.11 Using this technique, a new oral commissure is planned at a point 2 mm lateral to the native commissure to correct for expected postoperative scar contracture. An incision is then performed through the skin and muscle to completely the scarred tissue while preserving the native, undamaged mucosal tissue. Mucosal flaps from the cheek are then advanced along with the remaining vermilion to close the defect (Figure 3). The authors note that these cheek mucosal flaps tend to be more reliable and successful when compared with techniques in which only the vermilion is advanced into the defect; however, a
downside to this technique is that it can also result in shortening of the oral aperture on the affected side.11 Another technique that builds on the use of lip or cheek mucosal advancement flaps has also been described in a small series of patients.35 Using this technique, the oral commissure scar is partially excised, and buccal mucosa is advanced into the apex of the commissure (Figure 4). Splitthickness skin grafts are then taken from the adjacent lip tissue and are used to cover the existing raw surface of the injured vermilion. A full-thickness graft is then taken from the preauricular skin to reconstruct the skin immediately lateral to the oral commissure. This helps to blend the lateral aspect of the scar into the surrounding cheek. This technique has a number of distinct advantages. Firstly, the cosmetic deformity seen after oral commissure burns and reconstruction frequently extends onto the skin lateral to the oral commissure, an area that is not directly addressed with the use of vermilion or cheek advancement flaps.36 In addition, simple advancement of the adjacent vermilion into the wound bed tends to result in a “bunching” effect that adds some bulk to the oral commissure and results in a poor cosmetic match at the mucocutaneous junction.36 The use of a ventral tongue flap has also been described in small case series for the reconstruction of electrical burns of the oral commissure.34 An advantage of using a tongue
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Figure 4 An example of an alternative method of oral commissure reconstruction. The oral commissure scar is partially excised (A) and a buccal mucosal advancement flap is advanced into the apex of the commissure (B). Vermillion grafts are taken from the contralateral lip and used to reconstruct the upper and lower lip in the region of the oral commissure (C) followed by a full-thickness skin graft placed lateral to the commissure (D) to reconstruct the adjacent injured skin.
flap is that the flap can include muscle to replace missing orbicularis oris while also providing increased vascularity and durability. In addition, a large volume of tissue can be mobilized in this fashion to repair extensive defects that may not be amenable to closure with other techniques.34 Although the cosmetic match between tongue tissue and the vermilion mucosa is not ideal, the authors believe it to be a better match than buccal mucosa.34 The flap is designed as an anteriorly based tongue flap, taking care to exclude the filiform papillae present on the dorsal surface of the tongue. The donor site is closed primarily, and the tip of the tongue flap is advanced to the medial edge of the lower lip defect (Figure 5). The remainder of the flap is used to reconstruct the lateral lower lip, and the flap is typically divided at 2 weeks.
Conclusions Oral commissure burns in the pediatric population remain a reconstructive challenge. In most circumstances, a delayed approach to repair is used, giving time for the initial wound to declare itself. The use of oral commissure splinting, although challenging in practice, has been demonstrated to help prevent the need for surgical reconstruction of the oral commissure in the future. If surgical reconstruction is necessary, the goals include maintaining both normal function and cosmesis. A number of different techniques have been advocated for reconstruction of the oral commissure, and each has particular advantages and drawbacks that may make it more or less well suited for a particular injury.
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Figure 5 An example of a pedicled ventral tongue flap used to reconstruct the oral commissure.
References 1. McCaig L, Nawar E: National Hospital Ambulatory Medical Care Survey: 2004 Emergency department summary. Advance Data From Vital and Health Statistics of the National Center for Health Statistics, 2006 2. Hing E, Cherry D, Woodwell D: National Ambulatory Medical Care Survey: 2004 Summary. Advance Data From Vital and Health Statistics of the National Center for Health Statistics, 2006 3. Herndon D, Rutan R, Rutan T: Management of the pediatric patient with burns. J Burn Care Rehabil 14(3):3-8, 1993 4. Hall M, Owings M: Hospitalizations for injury: United States, 1996. NCHS—Vital and Health Statistics of the Centers for Disease Control and Prevention 218(4), 2000 5. System N: Deaths: Final data for 1997. Centers for Disease Control and Prevention 47(1), 1999 6. Ruth G, Smith S, Bronson M, et al: Outcomes related to burn-related child abuse: A case series. J Burn Care Rehabil 24:318, 2003 7. Renz B, Sherman R: Child abuse by scalding. J Med Assoc Ga 81: 574, 1992 8. Al-Qattan M, Gillett D, Thomson H: Electrical burns to the oral commissure: Does splinting obviate the need for commissuroplasty? Burns 22(7):555-556, 1996 9. Celik A, Ergun O, Ozok G: Pediatric electrical injuries: A review of 28 consecutive patients. J Pediatr Surg 39:1233, 2004 10. Vorhies J: Electrical burns of the oral commissure. Angle Orthod 57(1): 2-17, 1987
11. Canady J, Thompson S, Bardacj J: Oral commissure burns in children. Plast Reconstr Surg 97(4):738-744, 1996 12. American Burn Association/American College of Surgeons: Guidelines for the operation of burn centers. J Burn Care Res 28:134, 2007 13. Ortiz-Monasterio F, Factor R: Early definitive treatment of electrical burns of the mouth. Plast Reconstr Surg 65:169-176, 1980 14. Thompson H, Juckes A, Farmer A: Electrical burns to the mouth in children. Am J Surg 88(884):466-477, 1954 15. Rose EH: Aesthetic restoration of the severely disfigured face in burn victims: A comprehensive strategy. Plast Reconstr Surg 111(744): 1573-1585, 1995 16. Zarem H, Greer D: Tongue flap for reconstruction of the lips after electrical burns. Plast Reconstr Surg 53:310, 1974 17. Orgel M, Brown H, Woolhouse F: Electrical burns of the mouth in children. J Trauma 15(285):285-289, 1976 18. De la Plaza R, Quetglas A, Rodriguez E: Treatment of electrical burns of the mouth. Burns 10(49), 1983 19. Edlich R, Nichter I, Morgan R, et al: Burns of the head and neck. Otolaryngol Clin North Am 17(361):361-388, 1984 20. Leake J, Curtin J: Electric burns of the mouth in children. Clin Plast Surg 11:669, 1984 21. Gifford G, Marty A, MacCollum D: The management of electrical burns in children. Pediatrics 47(113):113-119, 1971 22. Hartford CE, Kealy GP, Lavelle WE, et al: An appliance to prevent and treat microstomia from burns. J Trauma 15:356, 1975 23. Kazanjian V, Roopenian A: The treatment of lip deformities resulting from electrical burns. Plast Reconstr Surg 35(466):884-890, 1965 24. Fleury A: Electrical burns of the lips: A modified plan of treatment. Am Surg 25:328-331, 1959 25. Lawson W: Management of soft tissue injuries of the face. Otolaryngol Clin North Am 15:35, 1982 26. Egeland B, More S, Buchman S, et al: Management of difficult pediatric facial burns: Reconstruction of burn-related lower eyelid ectropion and perioral contractures. J Craniofac Surg 19(4):960-969, 2008 27. Pitanguy I, de Lima P, Muller P, et al: Electric burns of the lip. Compend Contin Educ Dent 10(30):30-34, 1989 28. Pensler J, Rosenthal A: Reconstruction of the oral commissure after an electrical burn. J Burn Care Rehabil 11:50, 1990 29. Larson D, Abston S, Evans D, et al: Techniques for decreasing scar formation and contractures in the burned patient. J Trauma 11:807-823, 1971 30. Morgan R, Nichter L, Haines P, et al: Management of head and neck burns. J Burn Care Rehabil 6:20-38, 1985 31. Colcleugh R, Ryan J: Splinting electrical burns of the mouth in children. Plast Reconstr Surg 58:239-241, 1976 32. Heinle J, Kealey G, Cram A, et al: The microstomia prevention appliance: 14 years of clinical experience. J Burn Care Rehabil 9(1): 90-91, 1988 33. Dougherty M, Warden G: A thirty year review of oral appliances used to manage microstomia, 1972-2002. J Burn Care Rehabil 24(6):418431, 2003 34. Donelan MB: Reconstruction of electrical burns of the oral commissure with a ventral tongue flap. Plast Reconstr Surg 95(7):1155-1164, 1995 35. Anderson R, Kurtay M: Reconstruction of the corner of the mouth. Plast Reconstr Surg 47(5):463-464, 1971 36. Vecchione TR: An approach to the late effects of oral commissure injuries. Aesthetic Plast Surg 10(2):105-110, 1986