Acute Care Facial Burns

8/9/2019 Acute Care Facial Burns

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Sulaimanya Burn CentreSulaimanya Burn Centre

Prepaired by: Dr.QutaibaAbdullahYassinDr.QutaibaAbdullahYassin


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Introduction


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SeveralSeveral

histor

ical

histor

ical

figuresfiguresalsoalsofavoredfavoredexcisionexcisionof facialof facialburnsburns


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Introduction


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EXCISION AND GRAFTING OF ACUTE FACE ANDNECK

BURNS


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4/Evaluations


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The technique for the excision andThe technique for the excision and

grafting is described later and has notgrafting is described later and has notchanged sincechanged since

--publication except for one thingpublication except for one thing19861986thethe

the delaythe delaybetween allograftingand autograftingisbetween allograftingand autograftingis

week insteadweek instead11

days.days.22ofof


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The operationThe operation

Those aesthetic unitsThose aesthetic unitsjudged

to be incapable of healingto be incapable of healing

withinwithin 33 weeks of the injuryweeks of the injury

are outlined with markers.are outlined with markers.


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Special OT Notes

Small unburned or healedareas must frequently be included inthe excisionto

preserve the aesthetic unit.

In some circumstances, aIn some circumstances, a

portion of an aesthetic unit will clearly not heal inportion of an aesthetic unit will clearly not heal in 33weeks, butthe area is small enough to be reconstructedweeks, butthe area is small enough to be reconstructed

later by excision and closure or with tissue expanders.later by excision and closure or with tissue expanders.

Inthis situation, excision and grafting either are notInthis situation, excision and grafting either are not

performed or are done with routine graftsperformed or are done with routine grafts

One must excise deeply enough to

preventthe bed from healing underneath the graft with

resultant graft loss This is accomplished by excising

deeply enough to remove the hair follicles


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The T-shaped central area of the face

are usually excised first/The eyelids1hemostasis is achieved with bipolar cauteryhemostasis is achieved with bipolar cautery

and epinephrine (I :and epinephrine (I : 1010,,000000))--soakedsoaked

Telfa pads.Telfa pads.

are done next.are done next./The medial canthal regions/The medial canthal regions22The excision is usually doneThe excision is usually done

with curved iris scissors or a No.with curved iris scissors or a No. 1515 blade.blade.

,,nosenose/The next area to be excised is the/The next area to be excised is the33

is then excisedis then excisedupper lipupper lip/The/The44

chinchinandand/ lower lip/ lower lip66,,55

TheGoulian

dermatome

with the

O.OO8-

inch

guard

is used

for


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leaving the four large flat areas:

the2-cheeks,the forehead, and the neck

Typically, it is not wise to exciseTypically, it is not wise to excise

all four areas atthe same time because the blood lossall four areas atthe same time because the blood loss

can be substantial, requiring rapid transfusions tocan be substantial, requiring rapid transfusions to

maintain blood volume.maintain blood volume.

These areas are usuallydone serially.

The Goulian dermatome is again used

but with the O.OIO-inch or 0.012-inch guard

and the

excision continues to normal bleeding tissue with no

remaining hair follicles.


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Ear burns are not excisedE

ar burns are not excisedbecause there is nobecause there is no

instrumentinstrument

adequate to excise the threeadequate to excise the three--

dimensional structuredimensional structure

ofthe ear.ofthe ear.


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After excision is complete,After excision is complete,

each area is covered witheach area is covered with

allograft.allograft.

The allograftThe allograftis placed with all ofis placed with all of

the attentionto detail that is used forthe attentionto detail that is used for

autograft, thatautograft, that

is, itmust be well secured withis, itmust be well secured with

staples, sutures,staples, sutures,


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Approximately I week postoperatively, the patientApproximately I week postoperatively, the patient

is returned to the operating room for autografting.is returned to the operating room for autografting.

The

allograftis carefully inspected to determine

whether it is adherentto the bed underneath. If

the allograft is loose, itmay meanthatthe excision was

not deep enough, in which case the excision and allograftingmust be repeated.

It is usuallyIt is usually O.OIO.OI88 toto 00..021021 inch in thickness in adultsinch in thickness in adults andand

00..008008toto 00..0 120 12 inch in children and obtained frominch in children and obtained from

if graft colormust be matched with the colorif graft colormust be matched with the colorscalpscalpthetheof healed or unburned areas. Ifthe entire face is to beof healed or unburned areas. Ifthe entire face is to be

grafted, the scalp is insufficient,and the harvesting mustgrafted, the scalp is insufficient,and the harvesting must

be done elsewhere.be done elsewhere.


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It isIt is

importantthatthe donor siteimportantthatthe donor siteafterafterbe planned shortlybe planned shortly

, before all donor, before all donoradmissionadmission

sites have been used tosites have been used to

resurface other body parts.resurface other body parts.


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@from earto ear overthe top ofthe skull,

@one fromtop of skull to nape ofneck overthe occipital

region,@and two smaller residual pieces from each

posterolateral area,

Resulting in four pieces of autograft.

Each area of scalp is then infiltrated with largeEach area of scalp is then infiltrated with large

volumes of salinevolumes of saline

flat orflat orepinephrine to make itepinephrine to make it000000,,500500containing I :containing I :. To achieve this, more solution is injected. To achieve this, more solution is injectednearly sonearly so

around the perimeter ofthe site to be harvested thanaround the perimeter ofthe site to be harvested than

inthe center. This is done just before harvestinginthe center. This is done just before harvesting

because the fluid leaves the scalp rapidlybecause the fluid leaves the scalp rapidly


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dressing"dressing"

is then applied that consists of fine mesh gauze,

the elastomermold (or foam if sufficient), and a pressure

garment bubble (Bioclusive

(Johnson & Johnson) is applied to the scalp, if it was

harvested, and is held in place by the pressure garment

bubble.

Bubble and elastomer

Plaster reinforcement.

Duplicastmold.Bubble and elastom


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Postoperatively, these devices are removed twice

daily. The grafts are inspected and any hematomas

removed, through I-cm incisions placed inthe relaxedskintension lines. If hematomas are large, we do not

hesitate to returnto the operating room and remove

the hematoma with general anesthesia. Patients are

givennothing by mouth for 3 days

Until the grafts are mature, usually for several

months, the patient wears pressure garments.

Silicone sheeting is also

sometimes placed underthe garments ormasks in an effortto reduce

hypertrophic scarring

After circumoral grafting, splinting and exercisesto minimize microstomia are necessary.

Foll0w up


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Steroid injections are used only rarely.Steroid injections are used only rarely.

are indicated (e.g., small hypertrophicare indicated (e.g., small hypertrophic

scars). The usual dose isscars). The usual dose is 4040 mglmLmglmL

triamcinolone,triamcinolone,

4040 toto 8080 mg monthly formg monthly for 66 toto 99 months.months.


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THANKS

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Acute Care Facial Burns