Facial Burns

Etiology

Burns to the face, like burns in general, can be divided into the following categories: Thermal, electrical, chemical, and radiation. Thermal burns are the most common. The extent of injury depends on the temperature and duration of exposure. Scald injuries typically result in partial-thickness burns as the fluid splashes off the body, whereas direct contact for prolonged periods can result in full-thickness injury.

Electrical burns account for a much smaller percentage of admissions for burns but do require special attention. They are primarily due to exposure to wiring, but would also include the rare lightning strike. Of special note, pediatric oral commissure burns from chewing through electrical wires have specific treatment goals that are discussed later in this chapter.[6] Electrical burns can present with benign skin changes that do not reflect the more devastating internal damages, potentially causing fractures, dislocations, cardiac arrhythmias, and rhabdomyolysis. Lightning strikes, while rare, can result in occult trauma to the head and neck.[7] 

According to the national burn repository, chemical burns account for approximately 3% of admissions for burns and can be caused by any number of household or industrial agents. Chemicals can cause damage via contact with skin, oral ingestion, or inhalation. Decreasing the duration of contact can drastically improve outcomes. The eyes are highly sensitive to chemical injury and should receive special attention in all facial injuries involving chemical exposure.

Radiation burns are most frequently caused by sun exposure but also include burns from ionizing radiation. This includes iatrogenic diagnostic or therapeutic radiation. After any potential decontamination, radiation burns are treated the same as other burns. Patients can suffer partial-thickness burns to the skin from sun exposure with the nose and tips of the ears most vulnerable and often forgotten when applying sunscreen. The majority, however, are superficial and do not seek care from a physician. Corneal burns can occur as a result of radiation exposure, most commonly from poor eye protection during welding and from sun exposure in extreme environments such as snowfields and altitude.[8]

Burn injuries are frequently unintentional, but self-harm, abuse, or assault needs careful consideration. Approximately 2% of burns are secondary to assault or abuse, and 1% are from self-inflicted harm.[9] The clinician should have a high level of vigilance for potential abuse and neglect, especially with vulnerable populations. In children and adolescents with facial burns, some consideration for nonaccidental trauma must be given.

Epidemiology

Burns to the face constitute a large percentage of all burns. As many as two-thirds of all burns have some association with the face.[10] Differences in age, region, social-economic status, gender, and even time of year can change the incidence of burn injury. Certain populations are at greater risk of severe injury and mortality from complications surrounding burn injury. It is important for the practicing clinician to recognize when burn injury is an indication of domestic or nonaccidental trauma. Physicians working in public health need to understand the epidemiology in order to make informed decisions regarding prevention

In the United States, non-geriatric adults represent the largest number of burn victims. This tends to be the case for women predominantly during meal preparation and for men in the workplace. Over a third of all burns are estimated to be due to workplace injuries. The majority of these occurred in younger men in construction, food service, and manufacturing.[11] Worldwide, poor countries tend to have a higher incidence of domestic burns secondary to the use of open flames while cooking.[12] This puts women and children at increased risk from open flame and inhalational injury. In developed countries, scald injuries in the kitchen and from hot water in the bathroom are common domestic hazards, with scald injuries exceeding the number of flame burns in children under five.[13] The geriatric population also tends to suffer from hot water scald injuries as opposed to flames.[14] As children get older and are playing unsupervised, flame injuries become more common, especially in single-parent households.

Fireworks are particularly implicated as a cause of burns to the face and eye.[15] These have decreased over time but remain a significant source of injury. In general, boys are three times more likely than girls to be injured with permanent disability or disfigurement occurring in about 10%.[16] Another specialized mechanism of injury is electrical burns to the mouth. One center saw an estimated 1042 pediatric patients over a 15-year period.[17] The mechanism of injury was primarily due to electrical outlets, electrical wires, or extension cords, and 60% of the patients were boys. Most were under the age of 5. In another study, the outcomes of 75 patients with oral burns seen over a 10-year period at a Children's Hospital burn Center were examined.[18] The majority were males with the most common etiology being chemical burns, followed by electrical injury and then hot liquids. Approximately 10% required intubation, and only about 20% required surgery acutely.

Burn injury is found in child abuse. Approximately a tenth of the cases of child abuse involve burn injury, usually concentrated in children under the age of ten.[19] Scalding is the most common form of burn injury, leaving distinct patterns. Donut-shaped burns on the buttocks, sparing of the soles of the feet, and "water lines" on the skin should alert the clinician to possible nonaccidental trauma. Scald from hot objects such as cigarettes or kitchen utensils also leaves patterned injury. One should be especially sensitive to inconsistent histories or evidence of other healed burns. The face is especially vulnerable in cases of abuse.

There are socioeconomic risk factors for a burn injury, as well.[20][21] This occurs in both the poor and in developed countries. In underdeveloped countries, risk factors such as open flames in the kitchen, lack of shoes, lack of water supply, and large families leading to poor supervision play a role. In the United States, single-parent households, poorly fireproofed homes, and dense living situations place children at special risk.

Overall, there seems to be a downward trend in the incidence and severity of burn injury worldwide.[22] This has been accompanied by improvements in mortality and hospital length of stay. Burns still remains a significant source of injury, and one has to be particularly conscious of at-risk populations. The practicing clinician must be cognizant of the socioeconomic factors that contribute to poor outcomes when treating the burned patient. Considerations such as the patient's ability to fill prescriptions, have transportation, follow up, and have appropriate support at home should be weighed in determining disposition.

History and Physical

The initial evaluation of the patient with facial burns starts with a good history and physical. In unconscious patients, one must rely on bystanders or EMS personnel. While the physical exam can direct care of burns to the face, information on the mechanism of injury can prompt the search for associated occult trauma or suggest potential inhalation injury or impending airway compromise.

The evaluation in the field starts with scene safety, limiting further injury, and stabilization of the patient. Considerations could include shutting down power for electrical hazards or decontaminating the patient. The extent of airway compromise and tissue injury is determined by the duration of exposure and whether the patient was in an enclosed versus open space. Clothing must be removed without peeling from adherent tissue to decrease further damage.

In the emergency department, the initial evaluation should follow the Advanced Trauma Life Support (ATLS) guidelines.[23] It is important to methodically evaluate the patient and intervene as life-threatening conditions are discovered. ATLS guidelines are proven methods for managing patients with traumatic injuries and suggest an ordered sequence. In practice, different members of the healthcare team will conduct the steps simultaneously.

The most important initial consideration of the patient with facial burns is the airway exam. Mucosal edema can develop rapidly and unexpectedly and take the provider by surprise. Typical indications for intubation are patients' failure to oxygenate, ventilate, or ability to protect their airway. For burns, there is a concern for rapid edema, and the decision to intubate should occur before this occurring. Advanced burn life support (ABLS) recommends the following criteria as indications for early intubations:

• Signs of airway obstruction: hoarseness, stridor, accessory respiratory muscle use, sternal retraction
• Extent of the burn (TBSA burn > 40 to 50%)
• Extensive and deep facial burns
• Burns inside the mouth
• Significant edema or risk for edema
• Difficulty swallowing
• Signs of respiratory compromise: inability to clear secretions, respiratory fatigue, poor oxygenation or ventilation
• Decreased level of consciousness where airway protective reflexes are impaired
• Anticipated patient transfer of large burn with airway issue without qualified personnel to intubate en route

Some burn centers have taken note that intubations have risks and can lead to unnecessary complications and questioned the predictive value of the traditional intubation criteria, in particular the presence of facial burns, carbonaceous sputum, and singed nasal hair.[24] In one retrospective review of 47 patients undergoing bronchoscopy after suspected inhalation injury, the sensitivity, specificity, and predictive values of these findings were poorly correlated with evidence of airway edema. The authors suggest that they should not act as absolute indicators for intubation.

Another study used flexible fiberoptic laryngoscopy to evaluate all burn patients meeting criteria for intubations using these traditional criteria over five years.[25] They treated some patients with steroids, monitored more than half, and repeated flexible fiberoptic laryngoscopy in six others, only one of which required intubation. Based on these findings, they suggest a direct airway examination using fiberoptic laryngoscopy is an acceptable strategy to avoid immediate intubation.

A group from Denver, U.S.A., retrospectively reviewed 218 intubated burn patients. [26] Of these, 67 were intubated for less than two days and defined as "unnecessary." They compared the traditional criteria listed above with the American burn Association (ABA) guidelines set out in 2011. They found that the ABA criteria were significantly more associated with long-term intubation than the traditional criteria with a sensitivity of 77% and a specificity of 46%. By adding singed facial hair and suspected smoking elation, they increased the sensitivity to 95% and specificity of 24%, thus creating the Denver guidelines, which are listed below. They recommended that patients meeting these criteria intubation should be strongly considered, and those not meeting the criteria could potentially be managed with close observation. The following are the Denver criteria:[26]

• Full-thickness facial burns
• Stridor
• Respiratory distress
• Swelling on laryngoscopy
• Upper airway trauma
• Altered mentation
• Hypoxia/hypercarbia
• Hemodynamic instability
• Suspected smoke inhalation
• Singed facial hair

A complete explanation of inhalation injury is beyond the scope of this topic, but as severe facial burns have an association with airway and breathing compromise, a brief mention of important considerations is appropriate. Inhalation injury can affect the upper airways from direct thermal injury, the tracheobronchial tree secondary to particulate matter, and systemically from the absorption of poisonous gases.[27] Treatment of inhalational injury must begin concomitantly with the initial history and physical.

Special considerations during the physical exam include a focus on sensitive facial areas. In any patient with a burn involving the face, it is important to assess the cornea. Contact lenses should be removed, the eye rinsed with copious fluids, and the cornea examined with fluorescein. If any eyelid or eye involvement is found, early ophthalmologic evaluation is recommended. The ears should be examined for cartilaginous involvement, and the tympanic membrane should be checked, especially with any type of blast injury.

During the physical exam, it is important to assess the total body surface area (TBSA) to guide your initial fluid resuscitation. Different methods for calculating TBSA exist. The rule of nines is conventional, practical, and efficient for quickly determining an initial estimate. If the burn area is smaller, the patient's hand (fingers included) represents approximately 1% TSBA. The Lund and Browder chart has been shown to be more accurate in assessing TBSA, but new technology-aided models have shown promise in more reliable and accurate assessments.[28] Only partial and full-thickness burns should be included in the calculation for fluid resuscitation.

Burns are classified by their depth of injury and are designated as superficial, superficial, and deep partial-thickness, and full-thickness. Superficial burns involve the epidermal layer only, are red, blanch with pressure, and are painful. Partial-thickness burns involve epidermal and dermal layers. Superficial partial-thickness burns are red, blanch, are painful, and blister. Deep partial-thickness burns are mottled, painful to pressures, and are wet and blistered. Full-thickness burns involve all layers of the dermis and extend into the subcutaneous tissue or deeper. They are differentiated by burn eschar and painless.

Evaluation

Ancillary testing such as x-rays and laboratory work is indicated only as dictated by the clinical picture rather than by routine. They are dependent on the need to search for further injury, especially in patients with major burns, associated trauma, or inhalation injury. Patients presenting from a structure fire, industrial site, and those with electrical injury will need special attention. After the primary survey is complete, any further imaging necessary to the secondary survey should be conducted in a search for occult trauma and inhalation injury. Significant burns or associated multi-trauma, baseline laboratory work, and aggressive imaging, including CT scanning, are appropriate.

Deleterious systemic effects of inhaled gases are primarily from carbon monoxide and cyanide. Evaluation for carbon monoxide is easily accomplished with CO-pulse oximetry when available and venous blood gas when not. The diagnosis of cyanide toxicity is a little more difficult. Clinically, the patient will demonstrate some mental status changes and a poor response to fluid resuscitation. A persistent lactic acidosis and carboxyhemoglobin concentrations greater than 10% in these patients should prompt treatment. Administration of hydroxocobalamin is a safe treatment with fewer side effects than sodium thiosulfate or sodium nitrite.[29]

Evaluation of electrical burns deserves special note as an external appearance can be quite benign, yet due to the path of the current, the patient can have significant occult injuries, including fractures, rhabdomyolysis, cardiac arrhythmia, and compartment syndrome.[30] While the entrance and exit wounds need to be assessed, patients should have an electrocardiogram and a period of observation on a cardiac monitor to assess for arrhythmia. Also, baseline laboratory work should be drawn searching for rhabdomyolysis.

Patients should be X-rayed aggressively for occult fracture after a good exam. Facial burns due to electricity can cause significant contractures and underlying tissue damage. Of note are oral commissure burns and children from biting through electrical cords. The path of the current through the body is not necessarily a straight line, and it depends on the various tissue resistances making the evaluation less certain. Lightning strikes are rare, have a highly variable presentation, and can have delayed onset of symptoms. Injuries can occur both from the electrical current and from the trauma associated with the strike itself. A good head and neck exam are essential in these patients, particularly of the tympanic membranes and corneas.[7]

Treatment / Management

In acute facial burns, particularly those that are associated with major burn injury, the principles of general trauma and burn care apply. Management will follow advanced trauma life support (ATLS) guidelines and focus on a primary survey combined with treatment of life-threatening complications as they are discovered, followed by exposure and treatment of specific injuries. In the prehospital setting, initial management consists of first establishing scene safety, preventing further harm to the victim or provider. Initial management consists of stopping the burning process, adequate exposure, and immediate transport to the nearest appropriate facility.[3]

In the emergency department (ED), the care of the patient will continue to follow ATLS principles. At major centers with numerous team members, multiple steps can be conducted simultaneously, expediting care. It is important to decontaminate and expose the patient. Solid chemicals should be brushed off. Neutralizing agents should be avoided as they often cause further thermal injuries from acid-base reactions. Ocular exposure to chemicals should be irrigated for at least 15 minutes with at least 1,000 mL saline solution.[31] Be cognizant during the resuscitation that burn patients are especially susceptible to heat loss and should be protected against iatrogenic hypothermia.

Airway compromise and inhalation injury are common with severely burned patients or patients with significant facial burns. Supplemental oxygen should be given to any patient sustaining facial burns to treat any concomitant carbon monoxide or cyanide poisoning.[23] Severe burns to the face imply a prolonged contact with thermal insult, placing the upper airway at risk. Burns cause a local cytokine-mediated inflammatory response, creating hyperpermeability of the microvasculature, leading to tissue swelling. For the patient who sustains any facial burns or inhalation injuries, local swelling can occur rapidly and immediately. Physiochemical changes in the extracellular spaces cause protein denaturation, increasing the oncotic pressures, increasing local edema. It is also important to be aware of the requirement for fluid resuscitation, which increases the hydrostatic gradient, ultimately pushing more fluid into the extracellular space, compounding the tissue edema from the initial insult. All this results in edema accumulating over the first 6-8 hours, and continuing to develop over the next day. Advanced Burn Life Support (ABLS) criteria emphasize the importance of securing an airway early to prevent much more difficult intubation later.[31] 

Rapid sequence intubation can be performed in the standard fashion in acute burn injury, but in burn victims 48 hours out from the event, depolarizing paralytics such as succinylcholine should be avoided. Intubating, the patient does also allow one to provide aggressive sedation and analgesia. Ketamine is a good choice for an induction agent as it is typically less associated with hemodynamic instability. However, in patients with catecholamine deficiency, such as patients with large burn injuries, ketamine has the potential to cause hypotension.[32] See the history and physical section for a discussion on findings indicating intubation.

Even if the patient sustains inhalation injuries, direct thermal injury below the larynx is less common as heat is poorly transmitted via humid air. Is important to be cognizant of the fact that chemical agents can cause parenchymal injuries to the lung. Additionally, damage to the epithelial cells impairs mucociliary transport, increasing inflammatory changes and edema, causing airway obstruction. Inhalation injury also leads to loss of surfactant, leading to atelectasis. The resultant airway compromise consists of airway obstruction, bronchospasm, shunting, and increased risk of infection. Wheezing and respiratory distress may be present on examination due to the obstructed airflow. Aggressive treatment with aerosolized bronchodilators decreases airway resistance and improves aeration. Nitric oxide has been proposed as another adjunct therapy. While early studies demonstrated some benefits, a meta-analysis argues against it.[33] Efficacy has also been shown for inhaled heparin and N-acetylcysteine.[29] Intravenous corticosteroids will also help treat the inflammatory process. Treatment may require intubation, mechanical ventilation, bronchoscopy for pulmonary hygiene, and potentially extracorporeal membrane oxygenation.(A1)

Combustion consumes oxygen and produces an atmosphere rich in carbon monoxide and cyanide. Carbon monoxide binds to hemoglobin with a 200 times higher affinity than oxygen. This prevents aerobic ATP production, significantly harming skeletal and cardiac muscle and potentially causing CNS demyelination. Patients have a variable presentation and do not always demonstrate signs of inhalation injury. Presumptive administration of 100% oxygen competitively binds to hemoglobin and decreases carbon monoxide toxicity. Overall, 100% oxygen decreases carboxyhemoglobin levels by about 50% every 20 minutes. Hyperbaric chambers have been shown to improve outcomes for patients with carbon monoxide poisoning, but usefulness is impaired by the availability and potential instability of the patient.[34] However, if the carboxyhemoglobin level is significantly elevated and the patient is hemodynamically stable enough for the hyperbaric tank, treatment should be considered.(B2)

Cyanide is also a product of combustion and readily absorbed by the lungs. Cyanide binds to cytochrome C oxidase of the electron transport chain, inhibiting aerobic ATP production, also significantly harming skeletal and cardiac muscle and potentially causing CNS demyelination. Persistent lactic acidosis despite adequate fluid resuscitation and normal or slightly elevated carboxyhemoglobin level indicates cyanide poisoning. If the patient has evidence of thermal inhalation of combustible materials, neurologic deficits, and the above laboratory derangements, it is recommended to consider treatment with hydroxocobalamin.

Burns involving 15 to 20% TBSA will likely develop hypovolemic shock, and aggressive early fluid resuscitation is indicated. Vascular access can be gained through burn tissue if needed, but avoiding burn tissue is preferred. Intraosseous access and central lines are acceptable alternatives. Burns with less than 10% TBSA rarely cause hemodynamic changes, and aggressive fluid rehydration is not indicated. It is recommended to start fluids initially during the primary phase and calculate the Parkland formula during the secondary survey. Ongoing resuscitation is titrated to physiologic response for long-term management. The goal is 0.5 mL/kg/h urinary output in the adult or 1 mL/kg/h in children (less than 14 years old or less than 25 kg). Urinary output exceeding these numbers increases the risk of worsening edema, causing worse clinical outcomes. Consider inserting a Foley catheter for further titration of fluids in regards to urinary output.[31]

Burn pain is very difficult to manage. Aside from the initial insult, the therapies used to manage the burn tissue such as dressing changes, debridement and grafting can also cause significant discomfort. Attention to pain control is critical as it has been shown that better control in the acute phase results in better long-term clinical outcomes and improved quality of life. Increased pain perception increases the inflammatory response, negatively impacting the long-term healing process.[35] Additionally, poor acute pain control is associated with long-term negative psychological outcomes such as posttraumatic stress disorder, anxiety, or other major psychiatric illnesses.[36] 

Individuals experience very different levels of pain, and it is not possible to determine optimal pain management by assessing TBSA or depth of the burn. The initial pain is nociceptive, followed by neuropathic as the burns start healing. Various methods of quantifying pain include numerical or expressional pain scales, vital signs, and clinical appearance. Initial post-burn physiologic changes include decreased cardiac output, increased systemic edema, and decreased albumin concentrations, all of which alter the pharmacokinetics and pharmacodynamics of pain medications. In addition, there is an increased volume of distribution for all pain meds. Initially, there is decreased filtering from the liver and kidney, increasing the effect of the pain medications, but eventually, the hypermetabolic phase begins, and drugs are processed at a much faster rate, so increased dosage requirements can occur.[37]

Pain management is best treated using the multimodal approach, using multiple agents for pain control simultaneously. Patient-controlled analgesia (PCA) has been shown to effectively manage pain in hospitalized burn patients and should be used in conjunction with oral agents such as Acetaminophen, non-steroidal anti-inflammatory medications, Gabapentin, muscle relaxers, anxiolytics, and regional blocks. Ketamine is good for induction, but also before painful procedures such as dressing changes or grafts. Regional blocks could also be instituted before a painful procedure to optimize pain control during and immediately after the procedure. Anxiety is a common manifestation after burn injury, so anxiolytics should be an important component to pain management.[38] Benzodiazepines can decrease pain when used in conjunction with opioids but also cause delirium. Antipsychotic medications have been shown to decrease anxiety. Dexmedetomidine has been shown to have sedation and analgesia and be effective in weaning patients for extubation.[39](B2)

The initial care of facial burns includes cleansing and decontamination of the wound while avoiding further tissue damage. Initial burn management will consist of removing debris and cleaning the burn-injured area. For facial burns, chlorhexidine should be avoided as it is toxic to the cornea, and any contact with the eye could cause further injury.[40] Iodine is also not recommended secondary to the staining effect. Gentle soap and water or copious irrigation with saline is preferred. Aggressive scrubbing should be avoided to minimize trauma to the tissue. The selected dressing and topical agent should keep the wound surface moist without excessive exudate. The full extent of the injury caused by a burn is not always known initially, and they should be reexamined after a short period of healing. Further burn dressings can be tailored to the appearance of the wound at 48 hours.[41]

The main goals for the application of antibiotic ointments and dressings for burns to the face are to prevent complications, limit damage, and provide protection and comfort for the patient. Patients with significant injuries often need surgical intervention due to the cosmetic importance and special functions of facial structures. This requires persevering as much tissue as possible during the initial phase of treatment. Providing appropriate dressings will give the surgeon the most tissue to work with and the patient the best chance for a good outcome.

Dressings for coverage of burns can be divided into categories of passive, interactive, and biologic. Passive wound dressings, such as traditional gauze pads, provide coverage for the wound and can be used in conjunction with topical agents to prevent adherence to healing tissue. Dry gauze should not be used as this will slough off any re-epithelialized tissue during dressing changes. Interactive products protect the wound while maintaining a clean moist environment for healing. Examples include semipermeable foam dressings, hydrogel, hydrocolloids, and alginates. Biologic dressings may be considered in clean, non-infected wounds and include bio-membranes and scaffolds to facilitate epithelial growth.

Semipermeable film dressings allow gas exchange but protect the wound from contamination with bacteria. They are ideal for minor abrasions and burns. They are impermeable to liquid, so they should not be used on wounds with high levels of exudate. Alginates, foam, and hydro-active dressings absorb fluids and would be considered for highly exudative wounds. They would be relatively contraindicated with fresh burn wounds in that they could dry out the tissue and extend the depth of injury. They could be considered for donor sites or older wounds that are highly exudative. Hydrogel dressings have high water content. They are good for dry or minimally exudative wounds and provide cooling and protection for burns. They are not a very effective barrier to bacteria. There is evidence that they do outperform traditional dressings in terms of wound healing.[42](A1)

Biosynthetic dressings are available commercially and appropriate for use in uninfected, clean, acute burns. Sheets can be used that will conform to the surface of the burn, making it an ideal alternative for the treatment of the face. These dressings do not have any inherent antimicrobial activity but can be used in conjunction with topical antibiotics. They are expensive, but there is evidence that there is an improvement in time to healing compared to more traditional methods.[42] Alternatively, they can also be used on skin donor sites after skin grafting. Other biologic dressings would include allografts, xenografts, and human amnion. These are applied once, prevent desiccation of the wound, and promote reepithelialization.(A1)

Topical agents are also important in maintaining a healing environment while preventing wound infections. Topical agents have the advantage of preventing wound adherence to the dressings, decreasing wound infections, and enhancing wound healing. The choice of a topical agent is not entirely clear with data on the efficacy that is somewhat mixed.[43](A1)

Perhaps one of the most ubiquitously used is silver sulfadiazine. While it is easy to apply and readily available, it should be used with caution on the face as it should not be used on burns near the eyes. It is associated with skin hypersensitivity, neutropenia, leukopenia, and should not be used in pregnant or breastfeeding women. Furthermore, in a systematic review of antibiotic therapy to prevent wound infection rate in burned patients, pooled results showed that silver sulfadiazine was associated with a higher risk of burn infection than many other options and is also associated with longer hospital stays and time to healing compared to skin substitutes. However, the quality of evidence was limited by small sample sizes and a significant risk of biases. [44] Silver-containing dressings have the disadvantage of skin staining, which is less ideal for facial burns.(A1)

Antibiotic ointments and combination ointments such as bacitracin, neomycin, and polymyxin B are easy to apply, are useful on the face, and can be used with frequent dressing changes.  They should be discontinued when signs of reepithelialization appear and have the potential for hypersensitivity and yeast colonization.  Mupirocin ointment is also an excellent option for the face.  It gives good staph aureus coverage and can be used with frequent dressing changes. Mafenide cream or solution is indicated for burns to the ears and nose as it penetrates cartilage and provides excellent eschar penetration. It has gram-negative coverage, including Pseudomonas. It has the potential to cause enough pain in a very small number of patients to require an alternative. Additionally, Mafenide is a carbonic anhydrase inhibitor and, if used in large quantities, can cause or significantly worsen existing metabolic acidosis.[45]

Other antiseptic agents such as aloe vera and honey have been suggested. Aloe vera is inexpensive, soothing, and easy to apply. It has been compared against silver creams with at least equal results.[46] It has also been noted that evidence from animal studies suggests that honey accelerates burn to heal. When the results of multiple trials are combined that are compared to silver sulfadiazine, the evidence did suggest that honey promoted better wound healing in terms of time to epithelialization and rates of infection.[47](A1)

In general, systemic antibiotic prophylaxis should not be used in burn patients.[44] There is no clear evidence that the rate of burn infection is decreased, nor is there a difference in the development of sepsis. Perioperative systemic antibiotics had no effect on the ultimate wound infection. In fact, systemic antibiotics increase the risk of secondary infections such as pneumonia, otitis media, and urinary tract infections. Some antibiotics can also increase the rate of methicillin-resistant staph aureus. Systemic antibiotics have poor penetration of burned tissue and have difficulty reaching the site of injury.[48] They may be indicated in clearly infected wounds. However, use as a prophylactic has not been shown to be effective.(A1)

Ocular burns can be devastating, resulting in disfigurement, vision loss, and corneal complications. Initial management should include copious irrigation with normal saline or lactated Ringer, as previously discussed, to stop the burning process.[49] Any type of eyelid involvement should trigger immediate steps in management. It is important to keep the cornea lubricated, conduct a fluorescein exam for corneal abrasions, and discuss the case with the on-call ophthalmologist to establish a treatment plan. A topical anesthetic is appropriate for immediate symptomatic management. Topical corticosteroids can help control acute inflammation, but carry some risk of harm. It is recommended to consult ophthalmology prior to the use of ophthalmologic corticosteroids. Further therapy should be managed by an ophthalmologist, which may include amniotic membrane transplantation, tarsorrhaphy, keratoplasty, limbal stem cell transplantation, corneal transplantation, and antiangiogenic therapy.[50] Surgical management has been shown to have increased long-term visual acuity versus medical management. The amount of surviving limbal tissue will determine the prognosis.[49](A1)

Eyebrow and eyelash hair also have an aesthetic component and play a role in reconstruction. Initial management should include shaving off any singed or injured eyelashes as this has been shown to decrease cornea discomfort and decrease conjunctival injection.[51] Eyelashes and eyebrows may need reconstruction. Unfortunately, there is an increased risk of low follicular mean survival, and hair implantations may require multiple surgeries. The most common transplant technique used is the follicular unit technique, but the individual situation and surgeon will dictate the specific surgical intervention. Other interventions include composite grafts or skin flaps. Eyebrow donor locations are usually the occipital scalp or the contralateral eyebrow. Eyelash donor locations usually come from the leg as it has been shown to have a better outcome with natural curl and less growth, requiring less upkeep and appearing more natural. Scalp hair is less desirable as it is straight and grows too fast.[52](A1)

Burns to the lip pose a significant risk to function, yet still have an aesthetic component. Early reconstruction is recommended in commissural burns to improve functionality. Even with significant physical therapy for months to years, patients with facial burns develop significantly reduced vertical and horizontal oral openings, limiting their functionality.[53] Despite the early reconstruction, microstomia is a common complication as the burns can affect the orbicularis oris muscles and other structures. Dynamic splints with intralesional steroid injections have been shown to improve outcomes.[54] Oral commissure repair usually involves a mucosal advancement flap for adequate results. Other options include local flaps or skin grafts. A novel technique using autologous full-thickness anal verge skin to reconstruct the vermilion border with good results has been described. The vermilion and anal verge tissue are both transitional epithelial tissue and similar in appearance.[55]

Like the nose, the ears are a cartilaginous structure that has the combined roles of aesthetics and functionality. Ears are affected in 30% of all facial burns. Ears are easily injured, as they have thin skin that covers a cartilaginous framework. The blood supply is tenuous and is easily compromised after a burn injury. It is important to take into consideration some basic tenants of ear care after a burn injury. This includes avoiding compression or tight dressings to the burned ears, initial debridement should be minimal, and shaving the hair around the ear can decrease the risk of infection. The burn should be cleansed with soap and water, and an antimicrobial ointment applied.[56] The use of mafenide acetate is preferred, as it is a small area and can penetrate into the cartilage to prevent microbial growth. Silver sulfadiazine is not recommended as it has the potential to cause pigmentation changes.[57](B2)

The unique shape of the ear makes reconstruction difficult. For minor damage, local flaps are typically used, but free flaps can be used if limited sites are available for grafting or for more extensive burns. Autologous costal cartilage is the preferred cartilage for grafting, but synthetic agents such as porous polyethylene are also potential options for re-creating the distinct appearance of the ear. Novel processes are becoming more available for reconstruction with expanding technology. For example, skin and cartilage engineering is closer to becoming a reality. Three-dimensional bioprinting of cartilage could potentially play a part in complex ear reconstruction.[58]

The nose is located in the central part of the face, with important social and emotional implications. Beyond the functional aspect of the nares, the nose is crucial to aesthetics and integral and how people interact with each other. Gross disfigurement can cause social and psychological distress. Surgical repair of the nose can take many procedures and last months to years, but it is important to get as good as a functional and aesthetic outcome as possible.

The nose is a complex structure consisting of mucosa, cartilage, and skin. Superficial skin damage only requires skin grafting for definitive repair. With any type of cartilaginous compromise, autologous grafts from septal, conchal, auricular, and costal donor sites are common. If there are more severe deformities, local grafts from the forehead are the most common flaps, as they are the most similar in appearance and easily accessible. If the forehead is unavailable, superficial temporal artery based flaps or other autologous flaps can be used for grafting.[59][60][61](B3)

In addition to the aesthetic aspect of the nose, functionality has to be taken into consideration. One noted complication of a burn affecting the nose is stenotic nares. This can be improved by reconstruction of the alae with cartilage and stenting the opening for days to weeks after the surgery.[62] Postoperative stenting has been shown to improve functional outcomes for breathing and decrease the need for further procedures.

Hydrofluoric acid is a special chemical agent requiring specific management. It causes systemic toxicity via tissue destruction by the corrosive hydrogen that enters circulation. The fluoride anion chelates with calcium and magnesium, creating local calcium depletion and resultant hyperkalemia through cellular death. Although it is always recommended to decontaminate chemical burns with copious irrigation and generally recommended not to apply any neutralizing agent, applying calcium gluconate to hydrofluoric acid burns can decrease pain and minimize systemic damage caused by the acid. If the patient was exposed to a large amount of hydrofluoric acid, systemic hypocalcemia could occur. Since fluoride is cleared renally, if there is a concern for systemic toxicity, diuretics and sodium bicarbonate, hemodialysis, and IV calcium gluconate and magnesium sulfate could be used for mitigating adverse effects. Hydrofluoric acid is common in glass manufacturing and as industrial and domestic cleaning agents. Cardiac dysrhythmias are a leading cause of death from hydrofluoric acid burns. Therefore it is recommended to administer IV calcium gluconate if there is a concern for a hydrofluoric acid burn.[63]

The electrical injury also deserves special mention. Duration of exposure, voltage, and path through the body influence the extent of the injury. Electricity to the heart can cause cardiac necrosis and conduction abnormalities. The most frequent dysrhythmia is atrial fibrillation, and ventricular fibrillation is the most serious dysrhythmia. Electricity to the brain can result in respiratory arrest, cranial nerve deficits, seizures, or various other abnormalities. With any resultant cardiac dysrhythmia from electricity, it is important to follow ACLS guidelines for resuscitation.[30] (see evaluation section on electrical injuries)

Differential Diagnosis

For the large majority of burns, the differential diagnosis is very narrow. When history is available, and the patient has distinct physical findings, the diagnosis is quite evident. However, in patients that are unable to give a clear history or in patients that are presenting after a period of time, there are some disease presentations that have overlap in terms of symptomatology and treatment requirements. Each of these affects the function of skin and underlying tissues to the extent that treatment in a burn care unit is appropriate.[64]

Stevens-Johnson syndrome is hypersensitivity erythema with a sudden onset and unknown cause.[65] It is characterized by "target lesions," which are erythematous multicentric circular lesions with a positive Nikolsky's sign. Several viruses have been implicated, such as herpes, Epstein-Barr, and HIV. It has also been associated with certain drug reactions. Lyell syndrome (toxic epidermal necrolysis) also presents with systemic toxicity. These lesions are macular and irregular with a dark center. Nikolsky's sign is also positive in this syndrome. It has been associated with multiple common medications such as antiepileptics, allopurinol, and penicillin.[66] 

Erythema multiforme is associated with symmetrical target lesions without blisters involving the extremity. The mucosa is spared. This usually occurs after an upper respiratory infection. Necrotizing fasciitis presents with acute necrosis of the fascia and muscle. It will cause sloughing of skin. It is caused by various bacteria, is rapidly progressive, and carries high morbidity. There are case reports of it presenting on the face as well.[67] Scalded skin syndrome is mainly a disease of infants. The lesions occur when exfoliative staphylococcal toxin splits dermal layers. Nikolsky's sign and blisters are present. Pemphigoid is an autoimmune disease. It causes blistering of the mucous membranes and skin as autoantibodies attack the basement membrane zone.[68] Finally, subacute cutaneous lupus presents with erythematous round scaling lesions. The face and scalp are involved as well as mucosa. Women are disproportionately affected more than men. 

Treatment of these patients will often mimic that required for burn patients in that the burn care unit provides the necessary environment for treatment. Topical therapy is necessary. Medications have to be closely monitored. An emergency escharotomy may be necessary for full-thickness lesions. Morbidity and mortality are improved in these cases when care is provided by personnel familiar with these principles.[64]

Prognosis

Patients with facial burns are often left with significant scarring and lasting effects. These are both cosmetic and functional. The initial management of facial burns is centered around restoring function. Subsequent restoration of appearance is also a critical piece of the healing process as we effectively use our face in communicating with the rest of society. This may require patients to undergo multiple procedures or, in the extreme, consider facial transplantation.[69] Patients undergoing reconstruction will have it tailored to their individual injuries as the extent of the burn may limit the ability of local flaps and donor skin or tissue. In general, one would try to use similar tissue to that lost by the burn for coverage, but remote donor sites for skin or cartilage are available with priority given to functional areas.

The eyelids require early attention. They are both cosmetic and functional, and early intervention improves outcomes. Burns to the eyelids can occur in as many as 20% of flame injuries to the face. They can lead to ocular damage and blindness. Sequelae include corneal ulceration secondary to eyelid deformities and exposure keratopathy. These are preventable but do require urgent ophthalmologic consultation and ongoing lubrication.[70] The practitioner must ensure the patient continues to lubricate the eye, and arrangements must be made to have the patient seen for possible early surgical intervention with the knowledge that repeated procedures may be indicated.  In a retrospective study of 57 children, the 17 who had an eye-related release within seven days of receiving the burn had significantly better outcomes than the 40 who had delayed surgical treatment.[71] A systematic review and meta-analysis on conservative versus acute surgical management of ocular, eyelid, and eyelash burns demonstrated that aggressive early surgical intervention improved visual acuity and overall improved outcomes.[50] Patients with severe burns to the eyelids have some options for reconstruction, and with skin grafting, they can save vision. Unfortunately, reconstructed eyelids do not always open and close normally, and movements of the head and neck may be required to keep the cornea lubricated.[72]

Oral burn contractures can cause significant functional impairment, but surgical intervention with splinting and skin grafting can result in a successful outcome.[73] Conservative, nonsurgical treatment may not be as effective. In a trial attempting nonsurgical management, twelve consecutive patients with full-thickness oral-facial burns were compared against 120 age-matched controls. In the intervention group, exercise was initiated early and continued until healed. Initially, the treatment patients had significantly reduced mouth opening. Afterward, there was a significant improvement, but they were still reduced from the control group. The study concluded that positive gains could be achieved with nonsurgical treatment, but the duration of rehabilitation is considerable, and a loss of function is inevitable.[53] Cosmetically, deformities to the lip are a significant challenge for plastic surgeons.[55] The anatomy is complex, there are many diverse functions of the lips, and the lip tissue is highly specialized. The philtrum of the upper lip requires specific attention. The absence of the philtrum can pose a cosmetic room, and re-creating the philtral dimple is difficult.[74] Good surgical technique, however, can result in excellent results. 

Nasal contracture is a complication of facial burns. This is particularly true in children due to facial growth. Staged surgery is sometimes necessary to release scar contracture and reconstruct the nose.[75] The nose is the center of the face, and it is important to get a good cosmetic result. Nasal reconstruction can be associated with multiple surgical procedures and long-term rehabilitation. It may take years to obtain a satisfactory social life after the deformity of a nasal burn.[59] Surgical reconstruction of the nose is difficult. Mucosa cartilage and skin all have functional and cosmetic requirements. Circulation of healing tissue also is an issue.[61] Local flaps may be limited due to burns elsewhere on the face.

Auricular involvement is common with burns to the face. Unlike the eyes and mouth, however, conservative management of auricular burns works for the majority of patients. At one center in which they were able to follow 89 patients with partial burns to the ear to healing, only one required skin grafting.[76] This resulted in an excellent graft take. Costochondritis and ear deformities were avoided in the others through careful attention to detail.

From a cosmetic standpoint, it is important to line up hairlines such as the eyebrows and scalp. Significant hair loss may be treated with transplantation. Attempts at hair transplantation have met with some success though it remains difficult to graft hair onto scar tissue due to poor blood circulation and stiffness. About three-quarters of the patients were able to achieve some sort of favorable outcome.[77]

The psychological aftermath of a major burn can be significant, with up to 30% experiencing symptoms of posttraumatic stress disorder (PTSD). It is sometimes difficult to predict who will develop symptoms, and screening should be done in all patients with significant burn injury; this is particularly true to burns to the face. PTSD-related symptoms are not isolated to the patients either. One study looking at close relatives of burn patients found high rates of PTSD.[78] Another group of researchers looked specifically at depressive symptoms of patients with facial burns.[79] Interestingly, they found that depressive symptoms after the burn and the patient's perception of scar severity correlated strongly with self-esteem scores as opposed to the actual severity. This suggests that routine psychological screening during hospitalization may help in predicting those patients who will need subsequent treatment. Chronic pain and neuropathy are another consequence of burn with as many as one in ten burn survivors.[80] Pruritus may often accompany neuropathic pain, and it is difficult to distinguish between the two though treatment with gabapentin and pregabalin have been shown to be effective.[81]

Mortality from a burn injury can be estimated by looking at various risk factors. A retrospective review of 1665 patients presenting to a major burn center was analyzed, and researchers identified three risk factors for death: age greater than 60 years, greater than 40% TBSA, and inhalation injury. The mortality percentages of 0.3%, 3%, 33%, and 99% correlate to 0, 1, 2 or 3 factors present.[82] This estimation can provide valuable information regarding management to the healthcare team and decision-making to the family.

Complications

During every aspect of care, there are potential complications or suboptimal outcomes. Failure to recognize the full extent of the injury, delayed treatment, poor initial care, and improper surgical technique can all lead to poor outcomes. As healthcare systems advance, there have been improvements in the rate of complication, but challenges still abound. Major burns are associated with an immunocompromised state, systemic inflammatory response, and hypermetabolism that predispose the patient to sepsis and multi-organ failure.[83] These complications can be mitigated with meticulous management, but some injuries are too severe to entirely prevent serious complications.

Loss of visual acuity can result from various ocular complications from facial burns but is usually secondary to exposure keratopathy. Palpebral retractions from cicatricial ectropion or lagophthalmos, expose the cornea, which leads to the development of corneal ulcers. Early evaluation by an ophthalmologist and corneal lubrication is recommended to prevent this outcome.[84] Chemical burns to the face can result in high intraocular pressure and are easily missed. Vigilance is necessary as increased IOP can occur in the acute phase and up to a month after the insult.[49]

Oral contractures are common complications after facial burns. This affects functionality and diminishes aesthetics requiring months to years of physical therapy. Oral burn recovery is typically evaluated by measuring the vertical and horizontal oral openings. Microstomia is a common complication of facial burns involving the lips or oropharynx. Commissural splints prevent contractures during the healing process.[85]

Nose reconstruction after a burn injury is complex, and a common complication is stenosis of the nares. In order to fix or prevent this complication, the surgeon releases the stenosis, reconstructs the nose, and applies graded stents to the nares over days to weeks. This approach has been shown to maintain long-term nasal patency.[62][86]

Auricular burns are relatively common with facial burns though complication rates are less common than other areas of the face. Reconstruction is typically difficult, given the unique shape of the ear.[87] Despite this, chondritis and cartilage necrosis are two complications that are preventable with meticulous wound management.[57] Additionally, excessive pressure dressings on the ears can lead to cauliflower deformities of the auricle and should be avoided.[88]

Facial burns are associated with psychological and social complications. Surgical reconstruction and effective pain management can mitigate the adverse effects through a process that could last for years. Early psychiatric involvement in the management of these patients is critical. Psychiatric disorders, such as acute stress reaction, anxiety, PTSD, depression, behavioral disorders, and others, can complicate recovery. Burn management is a complex process that involves the whole healthcare team, and early intervention can decrease psychological and social sequelae.[89]