Assessment, Operative Planning and Surgery for Burn Wound Closure

INTRODUCTION

The burn wound causes both local and systemic effects mediated by the host

responses of inflammation, regeneration, and repair. Initial physiological derangement

can give rise to shifts in fluids, electrolytes and proteins within body compartments

necessitating formal fluid resuscitation in large burns. Other gross

metabolic, endocrine, hematological and immunological disturbances can also

occur in these patients. The severity of burn injury depends on the etiology of the

injury, the percentage body surface area of skin damage and the depth of the burn.

The aim of burn wound management is to achieve early sound and durable healing.

The management of the burn wound is only one part of the management of

the burn patient as a whole.

ANATOMY

Depth of burn injury is divided into partial and full thickness skin loss, with

partial thickness burns being divided into superficial and deep types (Fig. 4.1).

This classification quantifies the amount of tissue damage into anatomical terms.

1. Erythema (1st degree burns)—involving the epidermis only, usually with

no blistering although desquamation can occur later on.

2. Partial thickness (2nd degree burns)—involves epidermis and varying

portion of dermis.

3. Superficial if sparing of significant proportion of hair follicles, sebaceous

and sweat glands and substantial portion of dermis.

4. Deep if destruction of large proportion of hair follicles, sebaceous and

substantial portion of dermis.

5. Full thickness (3rd degree burns)—destruction of epidermis, dermis

and all adnexal structures.

PATHOPHYSIOLOGY

The initial local effect of a burn injury can be divided histologically into three

differential zones of tissue damage and blood flow.

1. Zone of necrosis—tissue necrosis centrally due to destruction of tissue

by injury.

2. Zone of ischemia—surrounds zones of necrosis and can progress and

lead to a clinically apparent increase in the area of skin necrosis or depth

of injury.

3. Zone of inflammation (hyperemia)—surrounds zone of ischemia and

is manifested by increased vascular permeability with extravasation of

fluid from the intravascular to the interstitial space leading to edema.

The extravasation of water, electrolytes and macromolecules is immediate

and can be generalized in larger burns. It continues for 24-48 h

and if left untreated can lead to hypovolemic shock.

ESCHAR

The necrotic tissue resulting from a burn is known as eschar. It separates slowly

from underlying viable tissue and is a good substrate for microorganisms. If left

untreated it becomes colonized, contaminated and eventually infected. Infection

attracts white blood cells that can digest the interface and cause separation of the

eschar from the underlying viable tissue. Topical antimicrobial agents increase the

time to eschar separation.

ASSESSMENT OF THE BURN WOUND

The burn wound must be assessed clinically before a treatment plan can be

formulated. The following must be determined; the depth of the burn wound, the

size of the burn and the anatomical site of injury.

1) Depth of burn determined by clinical wound inspection and the pinprick

test (Table 4.1)

2) Size of the burn determined as percent of total body surface area

(%TBSA) using

a) Wallace’s “Rule of Nines” (Fig. 4.2)—useful for initial rapid estimation

b) Lund and Browder Chart (Fig. 4.3)—for a more precise estimation

c) Patient’s palm ~ 1% of their body surface area—useful for children

and smaller burns

Note: Children have larger heads and smaller limbs in terms of body surface

area compared to adults.

3) Anatomical Site—important functional and aesthetic areas include;

hands, feet, face, eyelids, perineum, genitalia, and joints. These areas

need special attention to optimize wound healing and prevent cosmetic

and functional problems secondary to hypertrophic scaring.

INITIAL MANAGEMENT OF THE BURN WOUND

Resuscitation, smoke inhalation and other injuries must be dealt with initially.

Maintenance of the airways, breathing and establishing venous access are paramount

and are discussed in other chapters. Following assessment of the burn

wound the following practical procedure may be required:

1) First Aid—cooling the burn wound soon after the injury (within 30

minutes) is beneficial in removing heat from the wound and limiting

tissue damage. It can also reduce early edema and protein extravasation.

Care must be taken, as prolonged or excessive cooling can be detrimental.

Irrigating the wound in a drench shower for a least 20 minutes

is essential in chemical injury.

2) Burn Blister—management is controversial with evidence of blister fluid

having both beneficial and deleterious effects. In general they should be

removed if large, over joints and produce functional impairment. Small

intact blisters can be left in situ to act as a biological dressing.

3) Escharotomies—required if circumferential full thickness burns of chest,

limbs or digits are present. In limbs/digits such burns impair circulation

and cause distal ischemia. Circumferential full-thickness chest burns

can restrict chest wall excursion and impair ventilation. Such burns require

mid-axial escharotomies performed either at bedside or in the

operating room. A scalpel or electrocautery device can be used to incise

through the full thickness burns down to bulging fat. The incisions

should extend into adjacent nonburned or less deeply burned tissue.

Since the wounds are full thickness, minimal analgesia or anesthesia is

required, but extension into less damaged tissue can be very painful.

The decision to perform escharotomy is a clinical one. If you think that a wound

may need an escharotomy-then do it! This is particularly relevant if an excision of

the clearly full-thickness wound will be done later. An escharotomy incision will

only improve outcome without risk of harm in that situation. Waiting for signs of

distal ischemia or absent pulses is too late!

Mixed depth full thickness/deep partial thickness injuries producing a similar

clinical picture can be treated with topical collagenase although this is not really a

substitute for formal escharotomies.

BURN WOUND HEALING

The amount of anatomical tissue destruction and the size of the injury are

important determinants of wound healing.

1) Erythema (1st degree burns) usually resolves without any untoward effect

within a few days.

2) Superficial partial thickness (2nd degree burns) wounds heal spontaneously

by re-epithelialization from epidermal remnants within two weeks

and leave few or no scars.

3) Deep partial thickness (2nd degree burns) wounds heal by a mixture of

granulation, wound contraction and epithelialization from epidermal

remnants and the wound edge. If left to heal spontaneously these wounds

take 2-4 weeks or longer to heal and are associated with a high incidence

of disfiguring hypertrophic scarring and scar contracture. These

wounds often need skin grafting.

4) Full thickness wounds (3rd degree burns) require surgical intervention

and split thickness skin grafting. This invariably leads to hypertrophic

scarring particularly at the edges of the grafts (marginal hypertrophy).

If left to heal spontaneously these wounds granulate, contract and epithelialize

from the wound margins. This process is prolonged, leaves

the wound susceptible to invasive infection, and leads to significant functional

and esthetic deformity.

5) Burn wounds that require skin grafts have a higher incidence of scar

hypertrophy if the grafting is performed after 14 days of injury and the

wound has no viable dermal elements. Burn wounds that are not going

to heal within two weeks should be debrided and covered with autologous

split skin grafts to minimize hypertrophic scarring.

TREATMENT PLANNING

Once the size, site, and depth of the burn wound have been estimated and

initial urgent measures have been undertaken, a plan of action must be formulated

for further management of the wound. This management plan will include

conservative and surgical options depending on the individual patient and the

type and site of the wound. In the discussion below our preferred options will be

given followed by other alternatives. In general our institution pursues early aggressive

surgical intervention in deeper injury to limit the duration of burn illness

and reduce associated morbidity and mortality.

Treatment planning depends on the assessment of the following factors:

• Patient’s general condition and co-morbid factors

• Patient age

• Burn depth

• Burn size

• Anatomical distribution of injury

MANAGEMENT OF SUPERFICIAL PARTIAL THICKNESS WOUNDS

The aim of management of these types of wounds is to promote rapid spontaneous

re-epithelialization with the minimum number of painful dressing changes,

and to prevent infection which can convert the injury to a deeper one that requires

skin grafting.

SMALL/MEDIUM SIZED SUPERFICIAL PARTIAL THICKNESS WOUND

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Preferred method

Biobrane®

For patients presenting within 24 h of their injury. After admission and stabilization

under sedation or anesthesia the burn blisters are cleaned, debrided and

all burned epithelium is removed. Biobrane® is applied to the wound in a circumferential

fashion around the limb or trunk so that it is tight and closely adherent

to the wound. The Biobrane® is secured by stapling it to itself. Care is taken not to

staple the Biobrane® to the patient as this can cause granulomas and the staples

are painful to remove. The Biobrane® is then wrapped with a standard dressing of

Polysporin/Mycostatin impregnated rolled gauze covered by elastic bandages. The

dressings are removed at 24 h to inspect the wound. Oral antibiotics with staphylococcal

coverage are given for seven days. If the Biobrane® is adherent after the

first day, no further dressings are required. As re-epithelialization occurs in 10-14

days the Biobrane® spontaneously separates from the healed wound.

If wound infection supervenes, the Biobrane® rapidly becomes nonadherent

and can trap any exudate produced by the wound. For this reason Biobrane® is

not used in patients presenting more than 24-36 h following their injury and in

larger wounds (> 40% TBSA). Biobrane® is also relatively expensive compared to

common topical antimicrobials.

ALTERNATIVE METHODS

Topical antimicrobials

Topical Silvadene (1% Silver Sulfadiazine) is the usual alternative for these

wounds. After cleaning the wound and debridement of the blisters, Silvadene is

applied topically to the wound which is then covered with a rolled gauze and elasticized

bandage. The Silvadene dressings are changed once or twice daily until reepithelialization

occurs and the wound is healed. This method requires frequent

dressing changes, which can be a painful. It is the method of choice for patients

presenting late after injury with a colonized wound.

Biological dressings

Biological dressings such as allograft skin, xenograft skin (porcine), human

amnion can all be used in a similar fashion to Biobrane® to physiologically close

the wound while re-epithelialization occurs. The problems associated with the

use of these products include availability, collection, storage, and transmission of

infection control and cost.

Other dressings

Conventional dressings such as Vaseline gauze or silicone sheet (Mepitel®) can

be used to cover the wound while re-epithelialization takes place. After application,

these dressings need frequent changes, which can be painful. These types of

dressing are useful for small burns (less than 5% TBSA).

Synthetic dressings such as Duoderm®, Omniderm® Tegaderm® and hydrocolloids

have all been used with some success to dress such wounds. Other semisynthetic

biological dressings such as Dermagraft TC® are also being evaluated

for use in this type of wound.

Exposure

After cleaning and debridement, wounds are left open in a warm dry environment

to crust over. The coagulum formed separates as re-epithelialization proceeds

underneath. Advantages of this method are comfort and no need for dressing

changes. Disadvantages of this method include prolonged inpatient treatment,

specialized ward and nursing requirements and higher infection rates. This technique

is now not commonly used apart from the treatment of specialized areas

such as the face, genitalia and perineum.

LARGE SUPERFICIAL PARTIAL THICKNESS INJURY (> 40% TBSA)

Preferred treatment

Allograft

These uncommon injuries are more prone to contamination and infection

and can have a high morbidity. Best results are achieved if allograft is applied

within 24 h of the injury. Under anesthesia the wound is cleaned and all blisters

and nonadherent epidermis removed. Allograft split skin grafts meshed 2:1 are

placed over the open dermal wound and secured with staples. It is important not

to open up the mesh on the allograft as this can lead to desiccation, infection and

deepening of the underlying wound. A standard graft dressing is applied. If the

burn is thought to be a little deeper, a mid-dermal burn. The burn can be debrided

with a dermatome at a depth of 10-15/1000 inch and allograft applied as

above. This wound should then go on to heal spontaneously without incorporation

or rejection of the allograft into the wound.

ALTERNATIVE METHODS

Other biological or semi-biological dressings

Xenograft skin can be used in a similar fashion to the allograft, but does not

usually adhere as well, leaving the wound open to desiccation, infection and pain.

Biobrane® can be used in the same way as for smaller injuries. There is a higher

rate of wound infection which can lead to loss of the Biobrane® and deepening of

the burn wound.

Topical antimicrobials

Topical antimicrobials such as silver sulfadiazine can be used for this type of

wound in a similar manner to that described above. It is the treatment of choice

for wounds that present late and are colonized, as by definition the wounds should

heal spontaneously. The dressing changes can be painful and are an ordeal for the

patient. There is a high incidence of wound sepsis, which can lead to deepening of

the burn wound, which may then necessitate skin grafting.

Other dressing

Simple nonbiological dressings such as Vaseline gauze or silicone sheets

(Mepitel®) can be used to dress the large partial thickness wound. These dressings

can be medicated with an antimicrobial agent. The dressings are covered with

rolled gauze, bulky absorbent pads and elasticized crepe bandages.

The dressings are left intact for three to five days unless wound exudate seeps

through the dressing. The dressing changes can be very painful and often the patient

needs a general anesthetic for the procedure. There is a high incidence of

invasive wound sepsis and deepening of the burn wound that often necessitates

surgery. This technique is not recommended for larger burns.

MANAGEMENT OF DEEP PARTIAL THICKNESS INJURY

(SMALL AND LARGE)

This type of burn has a significant morbidity in terms of time to healing, infective

complications and subsequent scarring. Conservative management leading

to spontaneous healing usually involves prolonged and painful dressing changes

and the resultant scar is invariably hypertrophic leading to cosmetic and functional

debility. Thus an early surgical approach that tries to preserve dermis and

achieve prompt wound healing is preferred.

PREFERRED TREATMENT

Total wound excision and grafting

Burns that are deemed to be deep partial thickness in nature are best tangentially

excised and the wound covered with autologous split skin grafts. The grafts

usually require meshing and the amount of wound that can be closed with autograft

depends on the donor sites available and the mesh ratio used. Cosmetically

and functionally sensitive areas such as the face and hands need thicker sheet

autograft for wound closure. If the burn size is large (20%) or if donor sites are

scarce, then temporary wound closure with allograft, xenograft or other biological

or semi-biological dressings may be required to close the rest of the wound

while the donor sites heal. Standard graft dressings are applied. The grafted areas

can be inspected five days later. Early inspection of the wound is recommended if

there was late presentation or colonization of the excised burn wound. This type

of total wound excision can be done in one stage if enough surgeons are available

or can be done in two or three stages within the first five days following the burn.

Patients with large burns need to return to the operating room for further grafting

when their donor sites are healed. This is usually done on a weekly basis.

ALTERNATIVES

Serial wound excision and grafting

This method is employed for larger burns where donor sites are scarce. The

surgical technique is similar to that given above but the amount of burn wound

excised is the amount that can be covered by meshed split skin grafts from the

available donor sites. Unexcised areas are treated with topical antimicrobials until

donor sites have healed and can be reharvested, usually 7-14 days later. The unhealed

areas of burn wound are susceptible to invasive wound infection before

they are excised and this treatment method has a higher morbidity and mortality

compared to early excision. The use of the topical antimicrobial flamacerium (silver

sulfadiazine and cerium nitrate) has been reported as decreasing episodes of

invasive wound infection, morbidity and mortality with this method of treatment.

Topical antimicrobials

The wounds can be treated with daily or twice daily applications of silver sulfadiazine

until wound healing is achieved. This may take up to 4-6 weeks and

involve the patient in prolonged and painful periods of dressing changes. There is

a higher incidence of invasive wound infection using this method with associated

deepening of the wound. Once healed there is a much higher incidence of hypertrophic

scarring which can be a bother functionally and cosmetically disabling.

This method is usually reserved for patients who are thought to be unfit for surgical

intervention and for smaller burns in functionally and cosmetically unimportant

areas.

FULL THICKNESS INJURY

Full thickness burns will not heal spontaneously unless very small and invariably

require skin grafting. The necrotic tissue usually requires excision and the

resultant wound requires closure to reduce the risks of invasive infection and systemic

sepsis. Prompt excision and wound closure reduces morbidity and mortality

inpatients with such injuries.

1) SMALL FULL THICKNESS INJURY (<>

Preferred method

Excision and autografting

By definition full thickness injuries will not heal spontaneously and require

wound closure with split thickness autografts. On presentation it is usually best to

excise these wounds in a tangential fashion and obtain wound closure with split

thickness autograft. Meshed autograft is used if larger areas need closure, whereas

sheet autograft is used for functionally and cosmetically sensitive areas such as the

hands and face. Grafts are secured to the wounds by staples or absorbable sutures

and are dressed in the standard fashion. Grafts and wounds are inspected on the

second day if the initial wound was infected or heavily colonized or on the fifth

day if not.

ALTERNATIVE TREATMENTS

Topical antimicrobials

Inpatients who are elderly or unfit for surgical intervention, conservative management

with topical antimicrobials can be used. The antimicrobial agent—usually

silver sulphadiazine—is applied once/twice daily until the burn eschar separates

and a granulating wound is present. This usually takes approximately three

to four weeks to occur and sometimes longer. This granulating wound can then

be covered with autograft to achieve wound closure. In certain cases small wounds

less than 5 cm diameter can be left to heal spontaneously by wound contraction

and epithelialization from the wound margins.

This method of treatment usually results in a higher incidence of invasive wound

sepsis, a longer inpatient stay in the burn unit and a longer time to wound healing.

It is not recommended except in the special circumstances given above.

2) MEDIUM/LARGE FULL THICKNESS INJURIES (> 10% TBSA)

Preferred treatment

Total burn wound excision and auto/allografting

The treatment of choice for medium and large full thickness injuries is total

excision of the burn wound and physiologic wound closure with split skin autograft,

allograft and/or synthetic skin substitutes. This early aggressive surgical

approach has been shown to improve mortality in certain patient groups with

such burns. It is a major surgical undertaking to do this in one sitting with the

larger burns (greater 40% TBSA) and needs a coordinated approach from the

surgical and anesthetic teams. The timing of surgery postinjury is critical as blood

loss in the 24 h postburn has been shown to be half that of surgery after this time

(Table 4.2). In centers when numerous surgeons and anesthetists are not available,

total wound excision can be staged over two to three operations removing

the wound within five days of the injury. The type of wound excision depends on

the state of the burn wound. Those patients presenting immediately following

their injury usually have an uncolonized wound, which can be excised in a tangential fashion with a skin graft knife. Those patients presenting late a few days

after injury will have a colonized or infected wound. Attempts to preserve subcutaneous

fat in these cases usually fail and can lead to invasive systemic sepsis; therefore

fascial excision is usually preferred in these circumstances.

Wound closure is performed with meshed split thickness skin autograft and

allograft if donor sites are insufficient. In large and massive burns special techniques

such as overlay grafting are used to cover large wound areas with widely

meshed autograft. After total wound excision the whole wound must be physiologically

closed with auto- or allograft or a synthetic skin substitute like Integra®.

In large burns where wound closure cannot be achieved primarily with autograft,

the patient returns to the operating room when the donor sites are ready

for reharvesting at which time allograft is changed and further autograft is applied.

This is usually done in stages on a weekly basis until the whole wound is

closed with autograft.

ALTERNATIVE METHODS

Serial excision and autografting

This surgical approach has been described above for deep partial thickness

burns and entails excision of as much of the wound that can be covered with

available autograft. The unexcised areas of burn are treated with topical antimicrobials

until the donor sites are ready to be reharvested. This method of treatment

has a higher morbidity and mortality in larger injuries and has generally

been abandoned.

Topical antimicrobials and autografting of a granulating wound

This approach is again similar to the one described above for deep partial thickness

injury. The wound is dressed on a daily or twice daily basis with a topical

antimicrobial until spontaneous separation of the eschar occurs leaving a granulating

wound. This is then closed with split skin autograft. This technique has a

high incidence of invasive wound infection and systemic sepsis and in larger burns

is associated with a high mortality. It is only suitable for smaller burns inpatients

who are unfit for surgical debridement of the burn wound. It is not recommended for younger, fit patients with larger injuries.

MIXED DEPTH INJURY

Although the descriptions above have alluded to specific depths of burn, in

clinical practice most burns are mixed depth with areas of superficial partial, deep

partial and full thickness injury in adjacent area. Treatment of such wound depends

on the mixture of each component part of the injury, as one will usually

predominate. In general superficial partial thickness areas should be left to epithelialize

while the areas of deeper injury require excision and wound closure.

SURGICAL PLANNING—ANATOMICAL FACTORS

Prior to commencing any operation, the surgeon must have a plan as to which

donor sites are going to be used, which anatomical areas are to be debrided, and

the technique used for debridement. It is essential to have an idea of how much

autograft is required, which areas are priorities for autograft coverage, the required

mesh ratios and where the harvested graft is going.

In smaller burns where donor sites and available graft is plentiful, the focus is

to minimize donor site morbidity and to maximize functional and cosmetic outcome.

Care is used when choosing donor sites, preferentially taking cosmetically

hidden areas such as the upper thighs and scalp. Sheet grafts are preferred. It is

probably unnecessary to use meshed grafts in burns less than 30% TBSA.

In major burns (<>

autograft in the smallest number of operations to maximize survival. In these

size burns, the number of operations required is estimated to be one operation for

every 10% TBSA burned. The sequence of areas to be autografted is variable depending

on the surgeon. In general, our practice is to cover the posterior trunk,

anterior trunk, lower limbs, upper limbs, and head and neck in order. This sequence

maximizes the area covered with autograft early in the course and allows

for earlier ambulation. Areas not covered with autograft have allograft placed,

which is removed when autograft is available at subsequent operations.

MANAGEMENT AND GRAFTING OF ANATOMICAL AREAS

In general sheet grafts should be used whenever possible, however this not

practicable in burns over 30% TBSA. The following considerations need to be

taken into account when grafting each anatomical area especially when mesh grafts

are used as contracture can occur in the line of the interstices.

TRUNK/BREAST

In general mesh graft interstices on the trunk should be placed horizontally.

Care should be taken to preserve the breast or breast bud, especially in females,

and to place enough skin with minimal mesh expansion into the inframammary

folds and the sterna area to try and reduce subsequent breast deformity. The umbilicus

should be preserved if possible.

BUTTOCKS/PERINEUM/GENITALIA

The buttocks are difficult to manage and skin graft take is poor. They are allprone

to fecal soiling and shearing and can be the site of repeated bouts of invasive

wound sepsis. It is often worth autografting them in the first operation, but

graft take can be disappointing. If the grafts fail it is then best to leave the area for

a time when the patient can be nursed prone while the grafts take. This is usually

done after all other areas are healed. It is not usually necessary to perform a colostomy

to prevent fecal soiling.

The perineum and genitalia are usually managed conservatively with grafting

of any unhealed areas later on in the course of surgical treatment.

LOWER LIMB/HIPS/KNEES/ANKLES/FEET

Mesh graft interstices on the lower limbs should run longitudinally along the

line of the limb except at the joints. At both knee and ankle joints graft expansion

should be minimized if possible and the direction of the interstices should be the

same as the axis of rotation of the joint i.e. perpendicular to the longitudinal axis

of the limb.

The skin on the sole of the foot is glabrous skin and is very thick and specialized.

It will commonly re-epithelialize despite what initially seems a full thickness

injury. The sole of the foot is best treated conservatively until it is apparent that

spontaneous re-epithelialization will not occur. In contrast the skin on the dorsal

aspect of the foot is very thin and often requires grafting. It is important not to use

widely meshed skin in this area as any significant hypertrophic scarring can cause

difficulties with weight bearing ambulation and fitting of shoes.

UPPER LIMB/AXILLA/ELBOW

The same principles apply to the upper limb as described above. Mesh interstices

should run longitudinally on the upper limb apart from the axilla and elbow

where the interstices should be parallel to the axis of rotation of the joint. It is

important not to widely expand the mesh over the joints.

HANDS

Great attention to detail must be paid to the hand to achieve optimal functional

results. The volar aspect of the hand is covered with specialized glabrous

skin, which usually heals and it is best to avoid grafting it if possible. The dorsal

skin is thin and usually requires grafting in deep burns. In general, sheet graft is

preferable to mesh graft and is best secured with catgut sutures. There is some

debate as to which way the grafts should be applied to the hand along the longitudinal

axis of the hand or perpendicular to it. There is no good evidence to suggest

one way is better than the other.

The key to functional success is early mobilization of the hand. Initially after

grafting the hand is dressed and splinted in the position of safety with the metacarpophalangeal

joints flexed at 70-90°, the interphalangeal joints at 180°, the wrist

in neutral or slightly extended and the thumb flexed and adducted at the metacarpophalangeal

joint. The grafts are inspected at five days and, if stable, mobilization

can be started. If sheet grafts are used they can be exposed with no dressing

during mobilization during the day with splintage at night.

Inpatients with large burns, repeated application of allograft may be required

until it is time to autograft the hands. It can be very difficult to maintain the

position of safety of the hand during this period with splintage alone especially in

children under two years of age. In these cases K-wires through the metacarpophalangeal

and interphalangeal joints may be required to maintain the safe position

of the hand.

FACE/NECK/EYELIDS

The face and neck are areas that are both cosmetically and functionally important.

Deep burns of the face are usually treated conservatively with either topical

antimicrobials or repeated applications of allograft until a viable wound bed is

present. Occasionally early excision of full thickness facial burns is performed and

allograft applied to prepare the wound bed. Conservative treatment tends to preserve

viable tissue and is preferred. Further application of allograft may be required

before donor sites are available to graft the face. Sheet allograft should be

used and placed on the facial wound in cosmetic units (Fig. 4.3).

Medium to thick sheet split skin autograft should be used for the face and

applied in cosmetic units to place marginal scars in natural skin crease lines. If

available, donor sites should be above the neck for optimum color and texture

match. The scalp is an excellent donor site for grafts destined for the face. To get

suitable sheet grafts, dermocleisis with a solution of epinephrine should be employed

and a powered dermatome with a four-inch guard should be used to get

grafts of maximum width.

The eyelids require special attention to prevent corneal injury. Early excision

and closure of eyelid burns reduces the incidence of corneal injury secondary to

exposure and should be a priority. In the short term temporary tarsorrhaphies

(suturing the upper and lower lids together) can be performed to protect the corneas.

When applying autograft to the eyelids thick split thickness graft should be

used and overcorrection should be performed putting more skin in than seems to

be needed as contraction can lead to corneal exposure. Throughout the course of

the burn injury the corneas should protected by regular application of eye ointment.