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Topical management of facial burns
burns 34 (2008) 903–911
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Review
Topical management of facial burns§ Jorge Leon-Villapalos, Marc G. Jeschke, David N. Herndon * Shriners Burns Hospital for Children, 815 Market Street, Galveston, TX 77550, USA
article info
abstract
Article history:
The face is the central point of the physical features of the human being. It transmits
Accepted 29 January 2008
expressions and emotions, communicates feelings and allows for individual identity. It contains complex musculature and a pliable and unique skin envelope that reacts to the
Keywords:
environment through a vast network of nerve endings. The face hosts vital areas that make
Topical management
phonation, feeding, and vision possible. Facial burns disrupt these anatomical and functional
Facial burn
structures creating pain, deformity, swelling, and contractures that may lead to lasting physical and psychological sequelae. The management of facial burns may include operative and non-operative treatment or both, depending on the depth and extent of the burn. This paper intends to provide a review of the available options for topical management of facial burns. Topical agents will be defined as any agent applied to the surface of the skin that alters the outcome of the facial burn. Therefore, the classic concept of topical therapy will be expanded and developed within two major stages: acute and rehabilitation. Comparison of the effectiveness of the different treatments and relevant literature will be discussed. # 2008 Elsevier Ltd and ISBI. All rights reserved.
Contents 1. 2.
§
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acute phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Antiseptic agents . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Antimicrobial agents . . . . . . . . . . . . . . . . . . . . . 2.2.1. Silver preparations . . . . . . . . . . . . . . . . 2.2.2. Mafenide acetate preparations . . . . . . . 2.2.3. Cerium nitrate preparations . . . . . . . . . 2.2.4. Hypochlorite solutions . . . . . . . . . . . . . 2.2.5. Antibiotic and antifungal preparations 2.3. Enzymatic debriding agents . . . . . . . . . . . . . . . 2.4. Amnion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5. Aids to hemostasis . . . . . . . . . . . . . . . . . . . . . . 2.6. Alternative remedies . . . . . . . . . . . . . . . . . . . . . 2.7. Allografts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Disclaimer: None of the authors have any financial relationship with the products described here or with people or organizations that could inappropriately bias this work. * Corresponding author. Tel.: +1 409 770 6731; fax: +1 409 770 6919. E-mail addresses: [email protected], [email protected] (D.N. Herndon). 0305-4179/$34.00 # 2008 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2008.01.025
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3.
4.
1.
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2.8. Xenografts . . . . . . . . . . . . . . . . . . . . 2.9. Skin substitutes . . . . . . . . . . . . . . . . Rehabilitation phase . . . . . . . . . . . . . . . . . 3.1. Face masks and pressure garments 3.2. Scar management preparations . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgements . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . .
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Introduction
There are a few anatomical sites in which the devastating effects of burns are more noticeable than in the face (Fig. 1). Loss of anatomical integrity disrupts the face regional aesthetic subunits [1], and the initial tissue damage, pain and swelling may lead to lasting or permanent deformity, abnormal scarring (Fig. 2), contracture, loss of function and psychological morbidity [2]. The main goal in facial burns should be restoration of the normal facial subunits, with acceptable or good anatomical balance and symmetry and a dynamic facial expression [3]. Excision and grafting [4,5] is considered the gold standard for the management of full thickness or deep, non-healing partial thickness burns in other parts of the body. The face, however, has a unique blood supply that supports remarkable self-healing, making topical management of deep seconddegree facial burns an important early treatment option. Surgery is universally recommended for partial or full thickness burns of the face that have failed to heal after a period of 2–3 weeks [6]. Many other references [7–9] deal with
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the surgical management of the burned face, which will not be discussed in this paper. For this review we defined topical management as a remedy, substance, device or skin substitute that is placed on the face. Advances in the understanding of burn tissue pathophysiology, technical refinements and a multidisciplinary approach have extended the role of topical therapy from their initial use in the acute phase to the stage of rehabilitation (Table 1).
2.
Acute phase
2.1.
Antiseptic agents
Antiseptics are topical agents designed to limit (bacteriostatic) or eliminate (bactericidal) the presence of microorganisms in the surgical wound. They reduce the bacterial count of the skin and can be used to cleanse the facial burn surfaces after injury or to prevent infection in the preparation of the skin prior to surgical debridement [10]. The initial cleansing of the facial burn may be achieved with an antibacterial soap (Techni-Care1 Surgical Scrub CareTech Laboratories, Inc.) to remove debris and quantify accurately the extent and depth of the burn. Otherwise, two types of antiseptic agents used in clinical practice, alcohol
Table 1 – Facial burns topical management options 1. Acute phase 1.1. Antiseptic agents 1.2. Antimicrobial agents 1.2.1. Silver preparations Silver creams Silver solutions Silver dressings 1.2.2. Mafenide acetate preparations 1.2.3. Cerium nitrate preparations 1.2.4. Hypochlorite solutions 1.2.5. Antibiotic and antifungal preparations 1.3. Enzymatic debridement agents 1.4. Amnion 1.5. Aids to hemostasis 1.6. Moisturizing agents and alternative medicine remedies 1.7. Allografts 1.8. Xenografts 1.9. Skin substitutes
Fig. 1 – Acutely burned face.
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2. Rehabilitation phase 2.1. Face Masks and pressure garments 2.2. Scar management preparations
burns 34 (2008) 903–911
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of toxicity and adequate local eschar penetration without systemic absorption. It should be inexpensive, and easy to apply and store. It also needs to provide a favorable wound healing environment and deliver a high concentration of active principle to a devitalized, devascularized and potentially necrotic wound. By using an adequate topical antimicrobial, the conversion to zone of coagulation necrosis (from zone of stasis) and the resultant unwanted sequelae will be reduced and the need for extensive debridement and subsequent grafting minimized. This is of fundamental importance in the face, where overzealous debridement will affect function and cosmesis more than in any other part of the body. The normal microbiology environment of facial skin changes when it gets disrupted by burns, with a shift towards infection with gram-negative organisms and/or fungal species present in nearby mucosal surfaces. If the process of initial colonization progresses to an established infection, the depth and extent of the burn may change. This is also influenced by the accompanying process of immunological weakness associated with extensive burns and the poor penetration in devitalized tissue of systemic antibiotherapy.
2.2.1.
Fig. 2 – Abnormal scarring following facial burns.
based and iodine based. Combinations of alcohol and the biguanide chlorhexidine gluconate offers optimum antisepsis as they integrate rapid onset of action (alcohol) with the lasting anti gram-positive, gram-negative bactericidal and viricidal effect of the chlorhexidine [11]. Its use on the face may be limited by reports of possible eye damage with chlorhexidine contact [12]. Povidone-iodine compounds have broad spectrum of antisepsis against both gram-positive and gram-negative bacteria, fungi, viruses, spores, protozoa, and yeasts. Despite its effectiveness, this iodine based preparation is painful and irritating when applied to raw areas of the skin. Early reports of fatal complications due to absorption of povidone-iodine compounds in topically treated burned patients [13] have found similar but minimally reported experience in current literature [14]. A comparison of the bactericidal effectiveness of chlorhexidine vs. povidone-iodine preparations failed to show differences in colony count or advantages with the use of either antiseptic [15].
2.2.
Antimicrobial agents
Topical agents that control and limit burn infection constitute the topical burn therapy par excellence. The characteristics of the ideal prophylactic topical antimicrobial agent and the benefits of their usage have been outlined by Monafo [16] in his seminal paper: broad spectrum with long standing action, lack
Silver preparations
The historical importance of silver-based compounds for control of wound infection has been known for many years. Silver preparations and silver sulfadiazine in particular are key products in burns surgery as they act on the potentially infected burn eschar limiting the extent of the non-viable tissue when surgery is either not possible or not the immediate first option, such as in facial burns. An excellent review about the effect of silver on burn wound infection [17] has outlined the different options in silver-containing products based in their silver delivery properties. The more active the silver ions are, the more soluble they are. Therefore, they are activated in aqueous environment and their antimicrobial activity is based on their capacity to intracellularly accumulate and produce changes in the bacterial wall and bacterial cell functioning. Contact of silver preparations with a sodium chloride environment will inactivate the compound by precipitating the silver ions to an insoluble salt. Despite their popularity and wide use, silver based modalities are not without complications and their irritant properties to the skin, that usually becomes black stained, and the possibility of systemic absorption has been widely documented [18].
2.2.1.1. Silver creams. Silver sulfadiazine cream 1% (Flammazine1, Smith and Nephew; Silvadene1, King Pharmaceuticals) is a water based white cream containing the insoluble active principle silver sulfadiazine in micronized form. It was introduced by Fox in 1968 [19]. Each gram of silver sulfadiazine cream 1% contains 10 mg of micronized silver sulfadiazine in a petroleum, alcohol and water miscible cream. In order to warrant therapeutic effect, the cream must be applied repeatedly at least every 24 h with a layer thickness of about 3–5 mm.
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Silver sulfadiazine provides effective local antibacterial effect against gram-positive bacteria, gram-negative bacteria, viruses and fungal species such as candida albicans. General precautions associated with its use include transient leukopenia [20], allergy to sulfa-containing drugs and wound healing delay due to its proven toxicity to keratinocytes and fibroblasts [21]. Local precautions include the formation of a thick yellow pseudo-eschar that can make the differential diagnosis with full thickness burns difficult. The use of silver sulfadiazine for facial burns is recommended with caution for the possibility of eye damage or ingestion of the product, though there is neither manufacturer advice against its use in this sensitive area nor definitive reporting stating such complications. The efficacy of silver sulfadiazine has been compared against other methods of treatment for facial burns such as bio-engineered skin substitutes [22], finding significant decrease in wound care time, pain and re-epithelialization time in the skin substitute group. A similar report comparing silver sulfadiazine and allografts [23] found decreased reepithelialization time and hypertrophic scar incidence in the allograft group.
the same treatment period, reducing the requirements for grafting [27].
2.2.2.
2.2.3. 2.2.1.2. Silver solutions. Silver nitrate solutions at a concentration of 0.5% are used in clinical practice as an alternative to silver sulfadiazine, with which it shares similar antimicrobial cover but less burn eschar penetration. Its use in facial burns is limited by the fact that it stains organic and non-organic material black and requires repeated applications to keep its activity and saturate the target tissue. Despite the fact that it can be used in cases of sulfa allergy, recognized complications with its use include methemoglobinemia (gray or cyanotic skin appearance) and electrolyte disturbances such as hypokalemia and hyponatremia due to its hypotonicity; biochemistry surveillance is therefore recommended with its use [24].
2.2.1.3. Silver dressings. Acticoat1 (Smith and Nephew, Hull, UK) is a bi-layered polyethylene nanocrystalline silver-based dressing attached to a soaking coat of polyester. By delivering silver at a regular rate to the wound once it becomes saturated with water avoids the rapid neutralization of silver occurring in other silver-based preparations [25]. Acticoat1 provides fast and lasting antibiotic action without the need for dressing change; the only important feature being the need to keep the dressing hydrated (saline or ion solutions will deactivate the active silver content). This is due to the fact that ionic silver becomes inactive once in contact with the wound contents, and in order to obtain adequate antimicrobial activity, it is necessary to have a continuous flow of active silver. This problem can be solved either by frequent applications of the component (such as in the case of 0.5% silver nitrate solutions) or by a sustained release of silver nanocrystalline active principle into the wound [26]. Acticoat1 can be applied to any anatomical location including the face and has proved a successful alternative to traditional silver sulfadiazine preparations in dedicated units with demonstrated less cost than silver sulfadiazine over
Mafenide acetate preparations
Mafenide Acetate (Sulfamylon1 Bertek Pharmaceuticals, Morgantown, WV) is a sulphonamide with quick and deep penetration into burn eschar and excellent antibiotic properties. These characteristics make it ideal for areas of the face where cartilaginous framework is exposed such as the ears. Its antibiotic cover includes both gram-positives and gramnegatives, with minimal antifungal activity [28]. Frequent application of these preparations (up to 2 h) may be necessary in order to keep adequate amounts in the wound environment as it is quickly absorbed. Preparations of sulfamylon1 at concentrations of 5 and 11.1% are available commercially. Local and systemic complications with its use have been described. Local complications include pain, inflammation and allergic reactions. The most severe systemic unwanted effects are its characteristics as a carbonic anhydrase inhibitor and induction of hyperchloremic metabolic acidosis [29].
Cerium nitrate preparations
Cerium nitrate is an antiseptic with excellent penetration in the burned tissue and wide activity against both grampositive, gram-negative and fungal species, especially if combined with silver sulfadiazine. Other properties that make its use attractive are the hardening effect in the burn esscar, effectively isolating the potential focus of necrosis, reducing the possibilities of bacterial colonization and improving the burn wound healing environment [30]. Despite the initial enthusiasm for the microbiological synergy of action that the combination silver sulfadiazineCerium Nitrate (Flammacerium1, Solvay, Israel) has experienced, specifially in European burns units [31–33], some reports found no benefit in outcome compared to silver sulfadiazine therapy; moreover, there was an increase in the gram-negative morbidity in the burn [34,35]. The side effects of this remedy are mainly metabolic; transient metheglobinemia has been reported [36]. A randomized multicentre phase IV clinical trial on the efficacy of flammacerium in the treatment of facial burns and the impact of facial burns on psychosocial well-being verified by the Association of Dutch Burn Centres is currently recruiting patients. This study (ClinicalTrials.gov Identifier NCT00297752), with provisional completion date August 2008 will compare the efficacy of treatment of facial burns between flammacerium and flammazine.
2.2.4.
Hypochlorite solutions
Hypochlorite solutions have been used in burn care including facial burns since its introduction for treatment of First World War injuries by the English chemist Henry Drysdale Dakin and the French surgeon Alexis Carrel. This report [37] ascertained the proper concentration of the solution to provide adequate antimicrobial activity without toxicity or wound healing delay. The authors found tissue toxicity, both in vitro and in vivo at concentrations of 0.25% but not at a concentration of 0.025%. They concluded that
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although concentrations below this level were nontoxic, they were not bactericidal either and suggested the safe use of a ‘‘modified Dakin’s’’ solution at a concentration of 0.025% as this was found to be ‘‘. . . therapeutically efficacious as a fluid dressing, since it preserves bactericidal properties and eliminates the detrimental potential on wound healing’’. Dakin’s solution needs to be applied regularly to the wound and may cause irritation and maceration to non-burned and viable tissue.
2.2.5.
Antibiotic and antifungal preparations
Neosporin1, Polysporin1 and Bacitracin1 are the most commonly used antibiotic ointments for the treatment of superficial burned areas, as their eschar penetration is limited. The Neosporin1 activity is due to the combination of three different types of antibiotics with different spectra, as it contains bacitracin (gram-positive activity) and neomycin and polymyxin B (gram-negative activity). Combinations of Neosporin1 with other antiseptic solutions such as iodine povidone have been reported as beneficial in terms of reduced pain and improved eschar penetration and infection control [38]. Polysporin1 (Polymyxin B and Bacitracin) is also used for superficial burn wound infection and its use has been described in combination with enzymatic debriding agents to provide a clean burn wound in partial thickness burns, with reported results superior to those obtained by silver sulfadiazine [39]. Topical nystatin powder at a concentration of 6,000,000 units/g has been successfully reported for eradication of resistant fungus [40].
2.3.
Enzymatic debriding agents
Enzymatic agents aiming to penetrate the burn eschar and separate it from the healthy unburned tissue have been sought for more than 50 years [41]. Its use in facial burns remain controversial and minimally reported; an evident lack of literature linking enzymatic debriding agents with facial burns was noticed whilst researching data for this review. Rosenberg et al. [42] stated the characteristics of the ideal burn enzymatic debriding agent as safe, simple, rapid, and effective, and are divided currently into two groups according to their composition and origin. Bacterial origin compounds include Collagenase1, (Clostridium Histoliticum), Sutilains1 (Bacillus subtillis) and Varidase1 (streptococcus). Agents originating from plants include Accuzyme1 (papaya origin combined with urea) and Debridase1 (bromelain/pineapple derived). The authors reported their positive experience with Debridase1 as superior in terms of speed, number of treatments completion of debridement and lack of side effects compared to other debriding agents. An excellent review by Klasen [43] on the nonoperative removal of necrotic tissue from burn wounds concludes that despite being an attractive form of treatment, enzymatic debridement has highly variable results and has not fulfilled its theoretical potential as a widely used option in the treatment of burns, with minimal report of cases of usage specifically in the face.
2.4.
Amnion
A specific protocol, description and indications for usage of amnion (from caesarean sections only) in the treatment of pediatric partial-thickness facial burns has been described recently by Branski et al. [44] from the Shriners Hospital for Children in Galveston, Texas. This is the first clinical trial showing the efficacy and safety of amnion in burn wound healing in an exclusively pediatric population. The authors enrolled in the study patients with partial thickness burns of the face, head and neck and a TBSA burn size under 40%. The depth of the burn was determined by experienced staff within 24–48 h of admission. Patients were then randomized to receive amnion and antimicrobial ointment or antimicrobial ointment only (1% Nystatin, 2% Polymyxin and Bacitracin) and monitored for wound healing. Healing time and amount of re-applications of facial dressings was significantly shorter in the amnion group, though scar assessment failed to show differences between the two application is now a consistent treatment option for partial thickness facial burns at our institution (Figs. 3 and 4)
2.5.
Aids to hemostasis
Adequate blood loss control is a fundamental part of the surgical planning of burn debridement. This is especially true in the face where terminal branches of important vessels ramify and anastomose to each other with a density not seen in other areas of the body. Unrecognized bleeding stops the adequate graft adhesion and hampers work of cover. We have included as management of facial burns topical remedies that are known to control bleeding and therefore improve outcome of the burn. Topical epinephrine and thrombin are known to reduce blood loss during burn excision and grafting [45]. Fibrin glue has been shown to be beneficial as adjuvant tool in the fixation of grafts and control of hematomas in facial burn debridement [46,47]. Fibrin sealants (Tisseel1, Baxter) are a new tool in controlling hemostasis locally. Their use is recent but studies already showing their benefits in burn care [48] are encouraging.
Fig. 3 – Amnion being applied.
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healing enhancement of partial thickness wounds. Though not a topical remedy per se, the inclusion of allograft in this review is due to the lack of definition of management for superficial to deep facial burns and to illustrate this, in a prospective study design [23] cadaver allograft appeared to be a superior biological dressing for shallow and deep partial thickness burns compared to open treatment with silver sulphadiazine.
2.8.
Fig. 4 – Amnion fully applied in a facial burn.
Clinical trials (ClinicalTrials.gov Identifier: NCT00181974) attempting to prove the efficacy of fibrin sealant in burn surgery are currently recruiting patients.
2.6.
Alternative remedies
Multiple remedies that are non-first line treatments for topical facial burn therapy have been reported. Despite this, their efficacy is very much recognized in environments where paucity of resources may persist. Honey has been used as a dressing for pediatric facial burns [49,50] successfully as it prevents bacterial growth, forms a physical barrier acts as an enzymatic debrider and promotes epithelialization and angiogenesis. A prospective study comparing honey with silver sulfadiazine [51] found that ‘‘. . . in honey dressed wounds, early subsidence of acute inflammatory changes, better control of infection and quicker wound healing was observed while in the SSD treated wounds sustained inflammatory reaction was noted even on epithelialization’’. Other units reported good results in facial burns using sucralfate cream [52] compared to silver sulfadiazine and povidone-iodine and topical papaya [53]. The advantages reported by the use of the dressing known as moist exposed burn ointment (MEBO) [54,55] over traditional topical burn antibiotic creams and consisting of a mixture of medical herbs in a media of wax and oil failed to be consistent when scrutinized by later studies [56]. Beta-Glucan preparations have been used effectively in facial burns, soothing pain and aiding healing. Beta-Glucan collagen has been proved effective in the treatment of partial thickness burns in children [57]. Aloe Vera preparations appear to accelerate the wound healing process and rate of re-epithelialization in first and second degree burns compared to traditional topical treatment [58]. Other treatments such as tea tree oil appear not to have been successful in the topical treatment of burns [59].
2.7.
Allografts
Cadaver allograft is the cover material of choice for closure of excised full thickness burn wounds [60] but it can be used for
Xenografts
Porcine skin xenografts represent an intermediate step in topical facial burn management, as they are used for temporary wound closure until full healing is achieved or as interim prior to autografting. They do not usually get assimilated by the wound, but there have been reports of meshed xenograft imprinting in the past [61].
2.9.
Skin substitutes
The advantage of skin substitutes over conventional open technique topical management has been reported [62] in terms of ease of care, reduction in costs, decrease of pain and improvement of wound healing. A recent publication compared and analyzed bioengineered skin substitutes with biological dressings and topical management in the literature [63], finding similar efficacy between the three options. Transcyte1 (Advanced Tissue Sciences, Inc., La Jolla, CA, USA), a collagen-coated nylon mesh seeded with neonatal fibroblasts [64] attaches quickly to a suitable wound surface, stimulating epithelialization. It has proven useful in the treatment of facial burns compared to other topical methods [22]. Alloderm1 (LifeCell, Woodlands, TX, USA), a skin substitute consisting of acellular human cadaver dermis has also proven useful in burns of the face either as a one or two stage procedure [65].
3.
Rehabilitation phase
Upon admission in the acute inpatient setting, it is important for the surgeon and therapist within the multidisciplinary team to note the distribution and depth of the patient’s facial burn involvement. The therapist must assess the potential for facial contractures and scar deformity and include these areas in the treatment plan. During the initial outpatient evaluation of a patient presenting with facial burn involvement, the therapist must assess the face and document existing contractures or deformity and potential for contracture or scar hypertrophy. The therapist must then formulate a plan for therapeutic management of the facial burn. One of the biggest challenges in rehabilitation management of the face is compliance with therapeutic interventions and orthotic devices. Use of pressure is indicated with deep second or full thickness burn following adequate wound closure. However, due to a variety of factors affecting scar formation, pressure is sometimes indicated with more superficial burn injuries and is often
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applied when a scar demonstrates the beginning stages of hypertrophy.
3.1.
Face masks and pressure garments
For many burned patients, the true battle that involves social integration and acceptance of self-image, deformities and contractures can be as hard if not harder than the survival of the burn wound itself. In order to deal with the issues related to scar management, the options of pressure garment fitting (to mature the scar and redistribute the structure of the collagen fibers) and facial mask fitting are available (Figs. 5 and 6). These options that deal with direct local effect of the surface of the burned skin should be considered an integral part of the topical burn management [66]. The most common form of scar compression utilized in the outpatient setting is through the use of a mask, of which there are multiple options available combining pressure garments and silicone masks of different specifications. The mouth and nasal openings in the mask can be modified to accommodate the use of a mouth spreader and/ or nasal obturators. Partial face masks may be fabricated and applied on those patients who do not require a full mask. The mask is removed during times of exercise, bathing and activities of daily living (i.e. eating, facial/oral hygiene). The use of pressure is indicated until scar maturation is achieved.
Fig. 6 – Face mask on a face burnt patient.
In our institution, we have a dedicated medical sculptor that deals with the design and fitting of the masks and garments. Once an order from the physician has been received, the patient is scheduled for facial impression and an accurate plaster facial cast of the patient is required in order to make the custom-fit silicone pressure mask. Once the mask/pressure garment is fitted, it needs to be worn for as long as possible; usually for 1 year until the scar matures, only removing it for short periods of comfort and hygiene. Necessary changes in the mask are performed as required, usually every 6–8 weeks. Computer-designed and manufactured face masks have been described [67], with this system claiming to be faster, more accurate, and less stressful for the patient and allows for greater control of the finished product.
3.2.
Fig. 5 – Facial pressure garment.
Scar management preparations
In addition to scar massage and skin moisturizing, contact media preparations are used topically on the abnormal scar areas in order to remodel unsightly, bulky areas in prominent areas of the face. Silicone sheets have been used for many years to soften the scar, prevent contracture and increase mobility [68]. The most likely mechanism of action is hydration of the scar by occlusion, and by doing so, they improve the texture, thickness and colour of hypertrophic scars. Other treatments for facial hypertrophic scars include topical vitamin A creams to improve size, pruritus and colour fading, and vitamin E creams that despite anecdotal reports, lack scientific proof of scar improvement [69].
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burns 34 (2008) 903–911
Conclusion
Management of facial burns remain one of the most argued topics in burns. The timing, strategy and options for treatment seem to follow a pattern of close observation and application of topical remedies over a period of 2–3 weeks until the burn declares itself towards resolution and healing or towards deeper necrosis. It is then when surgical options become more important. Topical management options extend beyond the acute stage of facial burns to the rehabilitation period with a vast array of remedies and devices at the disposal of the burn professional. We have attempted to provide a comprehensive approach to the different options available for topical management of facial burns, extending the original concept of topical antibiotherapy in the acute stage to options in rehabilitation/scar management stage.
Conflict of interest statement Pertaining to all authors listed on this paper, there are no financial and personal relationships and no conflict of interest.
Acknowledgements Our gratitude to Ludwik Branski (Burn research fellow), Roland Morales (Medical sculptor), Megan Polak (Physiotherapist), the medical photography department and the staff and patients at the Shriners Galveston Hospital for their help providing material, ideas and encouragement for this paper.
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Review
Topical management of facial burns§ Jorge Leon-Villapalos, Marc G. Jeschke, David N. Herndon * Shriners Burns Hospital for Children, 815 Market Street, Galveston, TX 77550, USA
article info
abstract
Article history:
The face is the central point of the physical features of the human being. It transmits
Accepted 29 January 2008
expressions and emotions, communicates feelings and allows for individual identity. It contains complex musculature and a pliable and unique skin envelope that reacts to the
Keywords:
environment through a vast network of nerve endings. The face hosts vital areas that make
Topical management
phonation, feeding, and vision possible. Facial burns disrupt these anatomical and functional
Facial burn
structures creating pain, deformity, swelling, and contractures that may lead to lasting physical and psychological sequelae. The management of facial burns may include operative and non-operative treatment or both, depending on the depth and extent of the burn. This paper intends to provide a review of the available options for topical management of facial burns. Topical agents will be defined as any agent applied to the surface of the skin that alters the outcome of the facial burn. Therefore, the classic concept of topical therapy will be expanded and developed within two major stages: acute and rehabilitation. Comparison of the effectiveness of the different treatments and relevant literature will be discussed. # 2008 Elsevier Ltd and ISBI. All rights reserved.
Contents 1. 2.
§
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acute phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Antiseptic agents . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Antimicrobial agents . . . . . . . . . . . . . . . . . . . . . 2.2.1. Silver preparations . . . . . . . . . . . . . . . . 2.2.2. Mafenide acetate preparations . . . . . . . 2.2.3. Cerium nitrate preparations . . . . . . . . . 2.2.4. Hypochlorite solutions . . . . . . . . . . . . . 2.2.5. Antibiotic and antifungal preparations 2.3. Enzymatic debriding agents . . . . . . . . . . . . . . . 2.4. Amnion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5. Aids to hemostasis . . . . . . . . . . . . . . . . . . . . . . 2.6. Alternative remedies . . . . . . . . . . . . . . . . . . . . . 2.7. Allografts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Disclaimer: None of the authors have any financial relationship with the products described here or with people or organizations that could inappropriately bias this work. * Corresponding author. Tel.: +1 409 770 6731; fax: +1 409 770 6919. E-mail addresses: [email protected], [email protected] (D.N. Herndon). 0305-4179/$34.00 # 2008 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2008.01.025
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2.8. Xenografts . . . . . . . . . . . . . . . . . . . . 2.9. Skin substitutes . . . . . . . . . . . . . . . . Rehabilitation phase . . . . . . . . . . . . . . . . . 3.1. Face masks and pressure garments 3.2. Scar management preparations . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgements . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . .
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Introduction
There are a few anatomical sites in which the devastating effects of burns are more noticeable than in the face (Fig. 1). Loss of anatomical integrity disrupts the face regional aesthetic subunits [1], and the initial tissue damage, pain and swelling may lead to lasting or permanent deformity, abnormal scarring (Fig. 2), contracture, loss of function and psychological morbidity [2]. The main goal in facial burns should be restoration of the normal facial subunits, with acceptable or good anatomical balance and symmetry and a dynamic facial expression [3]. Excision and grafting [4,5] is considered the gold standard for the management of full thickness or deep, non-healing partial thickness burns in other parts of the body. The face, however, has a unique blood supply that supports remarkable self-healing, making topical management of deep seconddegree facial burns an important early treatment option. Surgery is universally recommended for partial or full thickness burns of the face that have failed to heal after a period of 2–3 weeks [6]. Many other references [7–9] deal with
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the surgical management of the burned face, which will not be discussed in this paper. For this review we defined topical management as a remedy, substance, device or skin substitute that is placed on the face. Advances in the understanding of burn tissue pathophysiology, technical refinements and a multidisciplinary approach have extended the role of topical therapy from their initial use in the acute phase to the stage of rehabilitation (Table 1).
2.
Acute phase
2.1.
Antiseptic agents
Antiseptics are topical agents designed to limit (bacteriostatic) or eliminate (bactericidal) the presence of microorganisms in the surgical wound. They reduce the bacterial count of the skin and can be used to cleanse the facial burn surfaces after injury or to prevent infection in the preparation of the skin prior to surgical debridement [10]. The initial cleansing of the facial burn may be achieved with an antibacterial soap (Techni-Care1 Surgical Scrub CareTech Laboratories, Inc.) to remove debris and quantify accurately the extent and depth of the burn. Otherwise, two types of antiseptic agents used in clinical practice, alcohol
Table 1 – Facial burns topical management options 1. Acute phase 1.1. Antiseptic agents 1.2. Antimicrobial agents 1.2.1. Silver preparations Silver creams Silver solutions Silver dressings 1.2.2. Mafenide acetate preparations 1.2.3. Cerium nitrate preparations 1.2.4. Hypochlorite solutions 1.2.5. Antibiotic and antifungal preparations 1.3. Enzymatic debridement agents 1.4. Amnion 1.5. Aids to hemostasis 1.6. Moisturizing agents and alternative medicine remedies 1.7. Allografts 1.8. Xenografts 1.9. Skin substitutes
Fig. 1 – Acutely burned face.
908 908 908 909 909 910 910 910
2. Rehabilitation phase 2.1. Face Masks and pressure garments 2.2. Scar management preparations
burns 34 (2008) 903–911
905
of toxicity and adequate local eschar penetration without systemic absorption. It should be inexpensive, and easy to apply and store. It also needs to provide a favorable wound healing environment and deliver a high concentration of active principle to a devitalized, devascularized and potentially necrotic wound. By using an adequate topical antimicrobial, the conversion to zone of coagulation necrosis (from zone of stasis) and the resultant unwanted sequelae will be reduced and the need for extensive debridement and subsequent grafting minimized. This is of fundamental importance in the face, where overzealous debridement will affect function and cosmesis more than in any other part of the body. The normal microbiology environment of facial skin changes when it gets disrupted by burns, with a shift towards infection with gram-negative organisms and/or fungal species present in nearby mucosal surfaces. If the process of initial colonization progresses to an established infection, the depth and extent of the burn may change. This is also influenced by the accompanying process of immunological weakness associated with extensive burns and the poor penetration in devitalized tissue of systemic antibiotherapy.
2.2.1.
Fig. 2 – Abnormal scarring following facial burns.
based and iodine based. Combinations of alcohol and the biguanide chlorhexidine gluconate offers optimum antisepsis as they integrate rapid onset of action (alcohol) with the lasting anti gram-positive, gram-negative bactericidal and viricidal effect of the chlorhexidine [11]. Its use on the face may be limited by reports of possible eye damage with chlorhexidine contact [12]. Povidone-iodine compounds have broad spectrum of antisepsis against both gram-positive and gram-negative bacteria, fungi, viruses, spores, protozoa, and yeasts. Despite its effectiveness, this iodine based preparation is painful and irritating when applied to raw areas of the skin. Early reports of fatal complications due to absorption of povidone-iodine compounds in topically treated burned patients [13] have found similar but minimally reported experience in current literature [14]. A comparison of the bactericidal effectiveness of chlorhexidine vs. povidone-iodine preparations failed to show differences in colony count or advantages with the use of either antiseptic [15].
2.2.
Antimicrobial agents
Topical agents that control and limit burn infection constitute the topical burn therapy par excellence. The characteristics of the ideal prophylactic topical antimicrobial agent and the benefits of their usage have been outlined by Monafo [16] in his seminal paper: broad spectrum with long standing action, lack
Silver preparations
The historical importance of silver-based compounds for control of wound infection has been known for many years. Silver preparations and silver sulfadiazine in particular are key products in burns surgery as they act on the potentially infected burn eschar limiting the extent of the non-viable tissue when surgery is either not possible or not the immediate first option, such as in facial burns. An excellent review about the effect of silver on burn wound infection [17] has outlined the different options in silver-containing products based in their silver delivery properties. The more active the silver ions are, the more soluble they are. Therefore, they are activated in aqueous environment and their antimicrobial activity is based on their capacity to intracellularly accumulate and produce changes in the bacterial wall and bacterial cell functioning. Contact of silver preparations with a sodium chloride environment will inactivate the compound by precipitating the silver ions to an insoluble salt. Despite their popularity and wide use, silver based modalities are not without complications and their irritant properties to the skin, that usually becomes black stained, and the possibility of systemic absorption has been widely documented [18].
2.2.1.1. Silver creams. Silver sulfadiazine cream 1% (Flammazine1, Smith and Nephew; Silvadene1, King Pharmaceuticals) is a water based white cream containing the insoluble active principle silver sulfadiazine in micronized form. It was introduced by Fox in 1968 [19]. Each gram of silver sulfadiazine cream 1% contains 10 mg of micronized silver sulfadiazine in a petroleum, alcohol and water miscible cream. In order to warrant therapeutic effect, the cream must be applied repeatedly at least every 24 h with a layer thickness of about 3–5 mm.
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burns 34 (2008) 903–911
Silver sulfadiazine provides effective local antibacterial effect against gram-positive bacteria, gram-negative bacteria, viruses and fungal species such as candida albicans. General precautions associated with its use include transient leukopenia [20], allergy to sulfa-containing drugs and wound healing delay due to its proven toxicity to keratinocytes and fibroblasts [21]. Local precautions include the formation of a thick yellow pseudo-eschar that can make the differential diagnosis with full thickness burns difficult. The use of silver sulfadiazine for facial burns is recommended with caution for the possibility of eye damage or ingestion of the product, though there is neither manufacturer advice against its use in this sensitive area nor definitive reporting stating such complications. The efficacy of silver sulfadiazine has been compared against other methods of treatment for facial burns such as bio-engineered skin substitutes [22], finding significant decrease in wound care time, pain and re-epithelialization time in the skin substitute group. A similar report comparing silver sulfadiazine and allografts [23] found decreased reepithelialization time and hypertrophic scar incidence in the allograft group.
the same treatment period, reducing the requirements for grafting [27].
2.2.2.
2.2.3. 2.2.1.2. Silver solutions. Silver nitrate solutions at a concentration of 0.5% are used in clinical practice as an alternative to silver sulfadiazine, with which it shares similar antimicrobial cover but less burn eschar penetration. Its use in facial burns is limited by the fact that it stains organic and non-organic material black and requires repeated applications to keep its activity and saturate the target tissue. Despite the fact that it can be used in cases of sulfa allergy, recognized complications with its use include methemoglobinemia (gray or cyanotic skin appearance) and electrolyte disturbances such as hypokalemia and hyponatremia due to its hypotonicity; biochemistry surveillance is therefore recommended with its use [24].
2.2.1.3. Silver dressings. Acticoat1 (Smith and Nephew, Hull, UK) is a bi-layered polyethylene nanocrystalline silver-based dressing attached to a soaking coat of polyester. By delivering silver at a regular rate to the wound once it becomes saturated with water avoids the rapid neutralization of silver occurring in other silver-based preparations [25]. Acticoat1 provides fast and lasting antibiotic action without the need for dressing change; the only important feature being the need to keep the dressing hydrated (saline or ion solutions will deactivate the active silver content). This is due to the fact that ionic silver becomes inactive once in contact with the wound contents, and in order to obtain adequate antimicrobial activity, it is necessary to have a continuous flow of active silver. This problem can be solved either by frequent applications of the component (such as in the case of 0.5% silver nitrate solutions) or by a sustained release of silver nanocrystalline active principle into the wound [26]. Acticoat1 can be applied to any anatomical location including the face and has proved a successful alternative to traditional silver sulfadiazine preparations in dedicated units with demonstrated less cost than silver sulfadiazine over
Mafenide acetate preparations
Mafenide Acetate (Sulfamylon1 Bertek Pharmaceuticals, Morgantown, WV) is a sulphonamide with quick and deep penetration into burn eschar and excellent antibiotic properties. These characteristics make it ideal for areas of the face where cartilaginous framework is exposed such as the ears. Its antibiotic cover includes both gram-positives and gramnegatives, with minimal antifungal activity [28]. Frequent application of these preparations (up to 2 h) may be necessary in order to keep adequate amounts in the wound environment as it is quickly absorbed. Preparations of sulfamylon1 at concentrations of 5 and 11.1% are available commercially. Local and systemic complications with its use have been described. Local complications include pain, inflammation and allergic reactions. The most severe systemic unwanted effects are its characteristics as a carbonic anhydrase inhibitor and induction of hyperchloremic metabolic acidosis [29].
Cerium nitrate preparations
Cerium nitrate is an antiseptic with excellent penetration in the burned tissue and wide activity against both grampositive, gram-negative and fungal species, especially if combined with silver sulfadiazine. Other properties that make its use attractive are the hardening effect in the burn esscar, effectively isolating the potential focus of necrosis, reducing the possibilities of bacterial colonization and improving the burn wound healing environment [30]. Despite the initial enthusiasm for the microbiological synergy of action that the combination silver sulfadiazineCerium Nitrate (Flammacerium1, Solvay, Israel) has experienced, specifially in European burns units [31–33], some reports found no benefit in outcome compared to silver sulfadiazine therapy; moreover, there was an increase in the gram-negative morbidity in the burn [34,35]. The side effects of this remedy are mainly metabolic; transient metheglobinemia has been reported [36]. A randomized multicentre phase IV clinical trial on the efficacy of flammacerium in the treatment of facial burns and the impact of facial burns on psychosocial well-being verified by the Association of Dutch Burn Centres is currently recruiting patients. This study (ClinicalTrials.gov Identifier NCT00297752), with provisional completion date August 2008 will compare the efficacy of treatment of facial burns between flammacerium and flammazine.
2.2.4.
Hypochlorite solutions
Hypochlorite solutions have been used in burn care including facial burns since its introduction for treatment of First World War injuries by the English chemist Henry Drysdale Dakin and the French surgeon Alexis Carrel. This report [37] ascertained the proper concentration of the solution to provide adequate antimicrobial activity without toxicity or wound healing delay. The authors found tissue toxicity, both in vitro and in vivo at concentrations of 0.25% but not at a concentration of 0.025%. They concluded that
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although concentrations below this level were nontoxic, they were not bactericidal either and suggested the safe use of a ‘‘modified Dakin’s’’ solution at a concentration of 0.025% as this was found to be ‘‘. . . therapeutically efficacious as a fluid dressing, since it preserves bactericidal properties and eliminates the detrimental potential on wound healing’’. Dakin’s solution needs to be applied regularly to the wound and may cause irritation and maceration to non-burned and viable tissue.
2.2.5.
Antibiotic and antifungal preparations
Neosporin1, Polysporin1 and Bacitracin1 are the most commonly used antibiotic ointments for the treatment of superficial burned areas, as their eschar penetration is limited. The Neosporin1 activity is due to the combination of three different types of antibiotics with different spectra, as it contains bacitracin (gram-positive activity) and neomycin and polymyxin B (gram-negative activity). Combinations of Neosporin1 with other antiseptic solutions such as iodine povidone have been reported as beneficial in terms of reduced pain and improved eschar penetration and infection control [38]. Polysporin1 (Polymyxin B and Bacitracin) is also used for superficial burn wound infection and its use has been described in combination with enzymatic debriding agents to provide a clean burn wound in partial thickness burns, with reported results superior to those obtained by silver sulfadiazine [39]. Topical nystatin powder at a concentration of 6,000,000 units/g has been successfully reported for eradication of resistant fungus [40].
2.3.
Enzymatic debriding agents
Enzymatic agents aiming to penetrate the burn eschar and separate it from the healthy unburned tissue have been sought for more than 50 years [41]. Its use in facial burns remain controversial and minimally reported; an evident lack of literature linking enzymatic debriding agents with facial burns was noticed whilst researching data for this review. Rosenberg et al. [42] stated the characteristics of the ideal burn enzymatic debriding agent as safe, simple, rapid, and effective, and are divided currently into two groups according to their composition and origin. Bacterial origin compounds include Collagenase1, (Clostridium Histoliticum), Sutilains1 (Bacillus subtillis) and Varidase1 (streptococcus). Agents originating from plants include Accuzyme1 (papaya origin combined with urea) and Debridase1 (bromelain/pineapple derived). The authors reported their positive experience with Debridase1 as superior in terms of speed, number of treatments completion of debridement and lack of side effects compared to other debriding agents. An excellent review by Klasen [43] on the nonoperative removal of necrotic tissue from burn wounds concludes that despite being an attractive form of treatment, enzymatic debridement has highly variable results and has not fulfilled its theoretical potential as a widely used option in the treatment of burns, with minimal report of cases of usage specifically in the face.
2.4.
Amnion
A specific protocol, description and indications for usage of amnion (from caesarean sections only) in the treatment of pediatric partial-thickness facial burns has been described recently by Branski et al. [44] from the Shriners Hospital for Children in Galveston, Texas. This is the first clinical trial showing the efficacy and safety of amnion in burn wound healing in an exclusively pediatric population. The authors enrolled in the study patients with partial thickness burns of the face, head and neck and a TBSA burn size under 40%. The depth of the burn was determined by experienced staff within 24–48 h of admission. Patients were then randomized to receive amnion and antimicrobial ointment or antimicrobial ointment only (1% Nystatin, 2% Polymyxin and Bacitracin) and monitored for wound healing. Healing time and amount of re-applications of facial dressings was significantly shorter in the amnion group, though scar assessment failed to show differences between the two application is now a consistent treatment option for partial thickness facial burns at our institution (Figs. 3 and 4)
2.5.
Aids to hemostasis
Adequate blood loss control is a fundamental part of the surgical planning of burn debridement. This is especially true in the face where terminal branches of important vessels ramify and anastomose to each other with a density not seen in other areas of the body. Unrecognized bleeding stops the adequate graft adhesion and hampers work of cover. We have included as management of facial burns topical remedies that are known to control bleeding and therefore improve outcome of the burn. Topical epinephrine and thrombin are known to reduce blood loss during burn excision and grafting [45]. Fibrin glue has been shown to be beneficial as adjuvant tool in the fixation of grafts and control of hematomas in facial burn debridement [46,47]. Fibrin sealants (Tisseel1, Baxter) are a new tool in controlling hemostasis locally. Their use is recent but studies already showing their benefits in burn care [48] are encouraging.
Fig. 3 – Amnion being applied.
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healing enhancement of partial thickness wounds. Though not a topical remedy per se, the inclusion of allograft in this review is due to the lack of definition of management for superficial to deep facial burns and to illustrate this, in a prospective study design [23] cadaver allograft appeared to be a superior biological dressing for shallow and deep partial thickness burns compared to open treatment with silver sulphadiazine.
2.8.
Fig. 4 – Amnion fully applied in a facial burn.
Clinical trials (ClinicalTrials.gov Identifier: NCT00181974) attempting to prove the efficacy of fibrin sealant in burn surgery are currently recruiting patients.
2.6.
Alternative remedies
Multiple remedies that are non-first line treatments for topical facial burn therapy have been reported. Despite this, their efficacy is very much recognized in environments where paucity of resources may persist. Honey has been used as a dressing for pediatric facial burns [49,50] successfully as it prevents bacterial growth, forms a physical barrier acts as an enzymatic debrider and promotes epithelialization and angiogenesis. A prospective study comparing honey with silver sulfadiazine [51] found that ‘‘. . . in honey dressed wounds, early subsidence of acute inflammatory changes, better control of infection and quicker wound healing was observed while in the SSD treated wounds sustained inflammatory reaction was noted even on epithelialization’’. Other units reported good results in facial burns using sucralfate cream [52] compared to silver sulfadiazine and povidone-iodine and topical papaya [53]. The advantages reported by the use of the dressing known as moist exposed burn ointment (MEBO) [54,55] over traditional topical burn antibiotic creams and consisting of a mixture of medical herbs in a media of wax and oil failed to be consistent when scrutinized by later studies [56]. Beta-Glucan preparations have been used effectively in facial burns, soothing pain and aiding healing. Beta-Glucan collagen has been proved effective in the treatment of partial thickness burns in children [57]. Aloe Vera preparations appear to accelerate the wound healing process and rate of re-epithelialization in first and second degree burns compared to traditional topical treatment [58]. Other treatments such as tea tree oil appear not to have been successful in the topical treatment of burns [59].
2.7.
Allografts
Cadaver allograft is the cover material of choice for closure of excised full thickness burn wounds [60] but it can be used for
Xenografts
Porcine skin xenografts represent an intermediate step in topical facial burn management, as they are used for temporary wound closure until full healing is achieved or as interim prior to autografting. They do not usually get assimilated by the wound, but there have been reports of meshed xenograft imprinting in the past [61].
2.9.
Skin substitutes
The advantage of skin substitutes over conventional open technique topical management has been reported [62] in terms of ease of care, reduction in costs, decrease of pain and improvement of wound healing. A recent publication compared and analyzed bioengineered skin substitutes with biological dressings and topical management in the literature [63], finding similar efficacy between the three options. Transcyte1 (Advanced Tissue Sciences, Inc., La Jolla, CA, USA), a collagen-coated nylon mesh seeded with neonatal fibroblasts [64] attaches quickly to a suitable wound surface, stimulating epithelialization. It has proven useful in the treatment of facial burns compared to other topical methods [22]. Alloderm1 (LifeCell, Woodlands, TX, USA), a skin substitute consisting of acellular human cadaver dermis has also proven useful in burns of the face either as a one or two stage procedure [65].
3.
Rehabilitation phase
Upon admission in the acute inpatient setting, it is important for the surgeon and therapist within the multidisciplinary team to note the distribution and depth of the patient’s facial burn involvement. The therapist must assess the potential for facial contractures and scar deformity and include these areas in the treatment plan. During the initial outpatient evaluation of a patient presenting with facial burn involvement, the therapist must assess the face and document existing contractures or deformity and potential for contracture or scar hypertrophy. The therapist must then formulate a plan for therapeutic management of the facial burn. One of the biggest challenges in rehabilitation management of the face is compliance with therapeutic interventions and orthotic devices. Use of pressure is indicated with deep second or full thickness burn following adequate wound closure. However, due to a variety of factors affecting scar formation, pressure is sometimes indicated with more superficial burn injuries and is often
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applied when a scar demonstrates the beginning stages of hypertrophy.
3.1.
Face masks and pressure garments
For many burned patients, the true battle that involves social integration and acceptance of self-image, deformities and contractures can be as hard if not harder than the survival of the burn wound itself. In order to deal with the issues related to scar management, the options of pressure garment fitting (to mature the scar and redistribute the structure of the collagen fibers) and facial mask fitting are available (Figs. 5 and 6). These options that deal with direct local effect of the surface of the burned skin should be considered an integral part of the topical burn management [66]. The most common form of scar compression utilized in the outpatient setting is through the use of a mask, of which there are multiple options available combining pressure garments and silicone masks of different specifications. The mouth and nasal openings in the mask can be modified to accommodate the use of a mouth spreader and/ or nasal obturators. Partial face masks may be fabricated and applied on those patients who do not require a full mask. The mask is removed during times of exercise, bathing and activities of daily living (i.e. eating, facial/oral hygiene). The use of pressure is indicated until scar maturation is achieved.
Fig. 6 – Face mask on a face burnt patient.
In our institution, we have a dedicated medical sculptor that deals with the design and fitting of the masks and garments. Once an order from the physician has been received, the patient is scheduled for facial impression and an accurate plaster facial cast of the patient is required in order to make the custom-fit silicone pressure mask. Once the mask/pressure garment is fitted, it needs to be worn for as long as possible; usually for 1 year until the scar matures, only removing it for short periods of comfort and hygiene. Necessary changes in the mask are performed as required, usually every 6–8 weeks. Computer-designed and manufactured face masks have been described [67], with this system claiming to be faster, more accurate, and less stressful for the patient and allows for greater control of the finished product.
3.2.
Fig. 5 – Facial pressure garment.
Scar management preparations
In addition to scar massage and skin moisturizing, contact media preparations are used topically on the abnormal scar areas in order to remodel unsightly, bulky areas in prominent areas of the face. Silicone sheets have been used for many years to soften the scar, prevent contracture and increase mobility [68]. The most likely mechanism of action is hydration of the scar by occlusion, and by doing so, they improve the texture, thickness and colour of hypertrophic scars. Other treatments for facial hypertrophic scars include topical vitamin A creams to improve size, pruritus and colour fading, and vitamin E creams that despite anecdotal reports, lack scientific proof of scar improvement [69].
910 4.
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Conclusion
Management of facial burns remain one of the most argued topics in burns. The timing, strategy and options for treatment seem to follow a pattern of close observation and application of topical remedies over a period of 2–3 weeks until the burn declares itself towards resolution and healing or towards deeper necrosis. It is then when surgical options become more important. Topical management options extend beyond the acute stage of facial burns to the rehabilitation period with a vast array of remedies and devices at the disposal of the burn professional. We have attempted to provide a comprehensive approach to the different options available for topical management of facial burns, extending the original concept of topical antibiotherapy in the acute stage to options in rehabilitation/scar management stage.
Conflict of interest statement Pertaining to all authors listed on this paper, there are no financial and personal relationships and no conflict of interest.
Acknowledgements Our gratitude to Ludwik Branski (Burn research fellow), Roland Morales (Medical sculptor), Megan Polak (Physiotherapist), the medical photography department and the staff and patients at the Shriners Galveston Hospital for their help providing material, ideas and encouragement for this paper.
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