Face Burns: A 4-Year Experience

Abstract

Burns on the face pose unique management challenges because they are in a place that is constantly visible, so scars are hard to hide. The goal of this study was to review our experience of adult patients who had face burns. We performed a retrospective review of adult patients (≥18 years old) who were admitted to a regional burn center from July 2015 to June 2019 with face burns. Sex, age, ethnicity, burn etiology, burn size, and discharge status were collected from electronic medical records of the patients who met study criteria. Descriptive statistics, Student’s t-tests, and chi-square tests were performed in Stata/SE 16.1. Significance was defined as a P-value < .05. In 4 years, 595/1705 patients (~35% of admissions) were admitted with face burns. The mean age was 44.9 ± 17.0 (mean ± SD) years, with the majority being men (475, 80%). The mean burn size was 19.8 ± 20.9% TBSA with 10.1 ± 19.8% TBSA being third degree. The mean head burn size for any face burn was 2.8 ± 1.8% TBSA. The majority of burns were due to flames (478, 80%) and of those 122 (21%) were from accelerant use and 43 (7%) resulted from propane or butane use. Scalds caused 53 (9%), electric 25 (4%), hot tar 5 (1%), and chemical 5 (1%). Overall, 208 (35%) patients had grafting of some portion of their body, but only 31 patients (5.2%) had face grafting. The mean age of those with face grafting compared with patients who did not need grafting was 45.9 ± 13.8 and 44.9 ± 17.2 years, respectively. Patients who needed grafting had a mean third-degree burn size of 31.7 ± 25.4% TBSA and a mean head (including face) burn size of 4.7 ± 2.0% TBSA, whereas patients who did not need grafting had a mean third-degree burn size of 8.9 ± 18.7% TBSA and a mean head burn size of 2.7 ± 1.8% head TBSA. Patients requiring face grafts had longer lengths of stay, intensive unit stays, ventilator days, and mortality than those whose face burns healed spontaneously. Overall, head burns in adults were common within the 4-year time span we studied, but only a small fraction (5%) had face grafts. The patients who needed grafting for their head burns had significantly larger total body and face burns and had a 2.4-fold higher mortality rate compared to patients who did not need grafting. Most face burns were caused by flame, especially the use of accelerants or flammable gases. Prevention efforts should focus on avoiding the use of accelerants and being careful with flammable gases.

Burns to the face are common injuries and, if treated inappropriately, can lead to significant scars that are obvious to the public. Face burns are common because (except during the current COVID-19 pandemic) the face is almost never covered. Therefore, there is no barrier to protect the face from the heat source. Fortunately, the majority of face burns heal relatively rapidly and with minimal scarring. Deeper burns to the face present a more difficult dilemma since any area with delayed healing is prone to hypertrophic scarring and contracture. The burn surgeon must make the decision between allowing the wounds to heal spontaneously or proceed to skin grafting. Both options have the potential to lead to at least minimal scarring and potentially severe contractures. Once a facial scar is present, there may be options to improve its outcome, but it will never disappear. Since even minor scars of the face are obvious to the public, they can lead to profound emotional and social burdens. The goal, therefore, is to minimize the extent of scarring in any facial burn.

The goal for the treatment of any burn, but more importantly the face, is to allow the wound to heal with as little scarring as possible. Any partial-thickness burn should heal within 2 to 3 weeks in order to minimize the chance for scarring.¹ Once it is clear that the burn is deeper, one must use strategies to minimize scarring during skin graft procedures.² In addition, there are special pigmentation issues that need to be considered. We had previously reviewed our experience with grafting face burns in pediatric patients.³ The goal of this study was to review our experience with treating face burns in the adult population over a recent 4-year period.

METHODS

We performed a retrospective review of adult patients (≥18 years old) who were admitted from July 2015 to June 2019 with face burns. Sex, age, ethnicity, race, burn size, burn etiology, length of stay, intensive care unit (ICU) stay, ventilator days, and discharge status were collected from the electronic medical record of the patients who met the study criteria. The charts were reviewed to determine whether the face burns received skin grafts or had other surgery. The operative notes were also reviewed to determine whether allografting was performed prior to autografting or whether the wound was covered with a dermal matrix. The use of, and type of, dermal substitute was also documented. The study had Institutional Review Board approval from the University of California Davis.

Indications for Skin Grafting

Since this was a retrospective review, the actual indications for skin grafting were not documented. All burn surgeons follow a similar philosophy of care. If the face burn is obviously deep second degree to third degree, then the surgeon would proceed to excision and grafting at the next available operative day. For massive burns, we usually excise and cover the extremities and anterior trunk with autograft, allograft, or dermal substitute on the first setting (usually within 48 hours of injury). The back is excised and covered next, and the face is saved for last. The face excision and coverage operation is usually performed as the sole procedure since it has significant bleeding and requires more delicate work. If there is available donor skin the face may be covered immediately with autograft, or if bleeding is excessive, it is covered with allograft for later autografting. We do not use hydrodissection for thick eschar because it removes the eschar less rapidly. When the depth of the face burn is less clear, we typically will wait 7 to 14 days to decide to excise and graft the area. We do not use objective measures of the depth such as the laser Doppler because We believe that the uniformity of depth often varies throughout the face. In addition, patients have the best result when they heal their burns within 2 weeks.

If the area to be grafted is small, we will harvest the scalp to improve the color match. When the entire face needs grafting, we have developed the technique of matching the shape of the donor skin to match the shape of the face. Therefore, we harvest a “U”-shaped piece of skin and wrap it around the face to minimize any seams.^2,3 The major complication of deep face burns is an ectropion. Patients undergo massage and early pressure devices to minimize exposure keratitis. In addition, they receive artificial tears and ointments, and they wear moisture chambers. Patients who develop an ectropion are treated with contracture releases with full-thickness skin grafts if the ectropion cannot be managed conservatively.

Burn Etiology Classification

Burn etiologies were classified into one of the eight different categories for simplification: flame, scald, electric, hot tar, chemicals, dermatologic, medical related, other, and unknown. Flame included burns from accelerant/gels, aerosol cans, burning bedding/clothing, cigarettes/smoking material, fireworks, gasoline, gunpowder, hazardous materials, kerosene, lighters, open flames, paint/paint thinner, propane, structural, vehicle fires, and wild land/brush. Scalds included burns from boiling water, hot coffee, hot cooking oil, hot food, hot grease, hot soup, hot tap water, molten plastic, radiator/coolant, and steam. Electric included burns from alternating current (A/C) 220 to 1000 V (V), A/C > 1000 V, house current/A/C < 200 V, direct current (D/C), electrical, and transformers. Hot tar included burns from tar/asphalt. Chemicals included burns from alkali or acid from batteries. Dermatologic included skin loss from necrosis (purpura fulminans, leprosy leading to Advanced Necrotic Cutaneous Lucio Phenomenon), staphylococcal scalded skin, and toxic epidermal necrolysis. The other category included burns from friction, radiant heaters, radiation, and abrasions from being thrown from a motor vehicle.

Burns from flame were further classified into accelerant and propane/butane subcategories. Accelerant burns included those injuries caused by accelerant/gels, gasoline, kerosene, paint/paint thinner, and aerosol cans. Propane/butane included burns from lighters or propane.

Statistics

Descriptive statistics, Student’s t-tests, and chi-square were performed in Stata/SE version 16.1. Significance was defined as a P-value < .05.

RESULTS

From July 2015 to June 2019, 595 of a total of 1705 (34.9%) adult patients were admitted to the medical center with face/head burns. The mean age of the patients admitted was 44.9 ± 17.0 years, with a majority being male (80%), Caucasian race (52.1%), and not Hispanic or Latino ethnicity (78.5%; Table 1). Flames were the most common etiology of burns (80.3% of cases), followed by scalds (8.9%), and electric causes (4.2%). The mean total % TBSA, % full-thickness burn, and % head burn for any patient with a face burn were 19.8 ± 20.9, 10.1 ± 19.8, and 2.8 ± 1.8, respectively (Table 1).

Flames were responsible for the burns of 478 (80.3%) patients admitted during the study time frame (Table 1). There were 10 different unique etiologies of burns from flame (Table 2), and the most common were accelerants (25.5% of just flame burns), open flame (18.4%), and hazardous materials (16.1%). Overall, accelerants were responsible for the most face burns in the study, causing 20.5% of burns of all patients admitted with those injuries.

Of the 595 patients admitted with face burns, 31 (5.2%) patients had skin grafting on some portion of their face (Table 3). The age, race, and burn etiology were similar between the patients who needed face grafting and those who did not need grafting (Table 3). There was a significantly higher proportion of women (45%) who needed face grafting than those who were not grafted (19%, P = .003 by chi-square). Flames were the most common burn etiology in both groups and were responsible for 83.9% and 80% of cases that needed face grafting and those that did not, respectively (Table 3). Most of the individual etiologies from flame were similar between the two groups. The main difference between the two groups was that propane/butane did not cause any burns in the face grafting group but caused 8% of the burns in the no face grafting group (Table 4).

Patients who needed face grafting had significantly larger total body burns, head burns, hospital stays, ICU stays, and time on ventilators (Table 5). The mean percent TBSA, full-thickness burn, and head burn of patients with face grafting were 2.0, 3.6, and 1.7 times larger, respectively, than those without grafting (P < .001, Table 5, Student’s t-test). Patients with face grafting also had significantly longer stays in the hospital, with a mean of 69.7 ± 52.3 (mean ± SD) days compared to 18.4 ± 28.0 days in the group without face grafting (P < .001, Table 5, Student’s t-test). All patients with face grafts (n = 31) were admitted to the ICU, with a mean ICU stay of 61.2 ± 48.4 days; however, only 450/564 (79.8%) patients without face grafting were admitted to the ICU. The mean ICU stay was 3 times shorter without face grafting. Ventilators were used more often and for longer time periods in the face graft group. Eighty-one percent of patients with face grafts were ventilated, with a mean of 51.9 ± 43.4 days on a ventilator. Ventilators were only used in 39% of cases that did not need face grafting, and the mean time spent on ventilators was significantly shorter at 17.3 ± 33.4 days (P < .001, Student’s t-test). A significantly higher number of patients with face grafts died (19.4%) compared with those without face grafts (8.1%, P = .04, chi-square).

The philosophy in our burn unit is to perform tracheostomies for all patients who will probably need prolonged ventilator support or who have extensive face burns that will require major facial grafting. Fourteen (45.2%) of the face-grafted patients had a tracheostomy and 28 (5%) of those patients without face grafts received a tracheostomy (Table 5). The burn sizes of both groups receiving tracheostomies were quite large (47.9% TBSA/42.0% full-thickness and 48.9% TBSA/31.5% full-thickness for grafted versus not grafted, respectively).

Of the 31 patients who had face grafting, 20 had excision with direct autografting the face. Eleven of the patients had temporary coverage of their faces with allograft followed by placement of either a dermal substitute or autografting. The majority of the allografted patients had other areas of the body covered with autograft so a temporary coverage was required. Of the dermal substitutes, one patient received Primatrix^TM (Integra LifeSciences, Plainsboro Township, NJ), two received Integra^TM (Integra LifeSciences ), and one received Biodegradable Temporizing Matrix^TM (BTM^TM; Polynovo Biomaterials Pty. Ltd., Melbourne, Australia). All dermal matrices were eventually replaced with autografts. Eleven patients needed to have eyelid ectropion releases during their first admission. Two required releases despite not having any skin grafts and nine required releases after grafting. While 564 patients did not have grafting on their face, 217/564 patients did have grafting on some other part of their body. These 217 patients had a mean of 2.2 ± 2.0 visits to the operating room. This was significantly lower (P < .001) than the number of operating room visits that the 31 patients who had face grafting experienced, which was 4.5 ± 3.1 operating room visits.

DISCUSSION

Face burns occur in over one third of patients admitted to our adult burn center. They can be devastating to the patient if they leave even small scars since the changes are exposed to the public and can lead to stares and uncomfortable questions. The goal for the care of face burns is to minimize any changes in appearance that might be noticeable. While burns to the face are common, they have a reasonable chance for healing on their own. We found that only 6.6% had grafting for their face burns. There are some reasons that face burns require less grafting.² People tend to protect their face with their hands or other materials when exposed to heat. The face is usually not covered with clothing, so when hot liquid strikes, it can be rapidly shaken off and thus shorten exposure. It is common for scald burns to be deeper on the chest or legs since soaked clothing prolongs contact with the hot agent. The shorter exposure to heat reduces the depth of face burns. Additionally, the face has a very robust blood supply, which dissipates heat and thus reduces burn depth compared with an area with poor blood supply. Areas of the head that have a high density of hair will re-epithelialize partial-thickness burns quicker because the epithelial cells migrating from the hair follicles have less distance to travel. Finally, since there is a better chance for healing, there is a tendency to wait to see whether face wounds will heal on their own. There are occasions when most areas of the face burn heal, and the remaining open areas are not worth grafting. What this study did not reveal, however, is if those without grafting had less scarring than those patients who did. One could argue that the use of more objective measures to determine burn depth, such as the use of a laser Doppler, could improve outcomes, but we have not used these devices. We have little experience with the devices, and typically, there is not a uniform depth of injury so the decision to graft or not is still difficult.

Face burns, at least in adults, tend to occur more frequently in men and like most burns in adults, flame or fire was the most common cause of injury. For our study, 80% of face burns were caused by flames. This is a higher percentage than the 40.6% of burns caused by flame as provided in the 2019 National Burn Registry of the American Burn Association (NBR).⁴ When breaking down the types of flame burns it becomes apparent that the use of accelerants continues to be a major cause of facial injury. Despite many warnings, men still tend to use gasoline or other accelerants to start fires. In addition, there has been an increase in our experience with flame burns from butane since that agent is used to isolate the active ingredients of marijuana.^5,6 These etiologies should be targets for prevention.

When face burns are deep and require grafting, they are associated with larger burns (37% vs 19%) than face burns that do not require grafting. In addition, those that require grafting are associated with longer lengths of stay, more time on ventilators, and higher mortality. We perform more tracheostomies on those patients requiring grafting to the face for a couple of reasons. First, they tend to be patients with larger and deeper burns, so we anticipate that they will require prolonged ventilatory support. We have a philosophy of performing tracheostomies at the first excision and grafting procedure (usually within 1–2 days) in patients have massive burns.⁷ We will also perform tracheostomies for any patient who will require extensive grafting of the face since endotracheal tube ties interfere with graft application. We have not had major problems with the use of early tracheostomy.⁷

Our goal for all burn patients is to optimize functional and cosmetic outcomes in our patients. This strategy is emphasized in the management of face burns. We will use antimicrobial ointments (usually bacitracin) on face burns and try to maintain the moist environment that optimizes healing. If there is a chance that a partial-thickness burn will heal within around two weeks, then we will wait for the face to re-epithelialize. On occasion, there will be a relatively small area that remains open and the decision needs to be made as to wait for wound closure or graft the area. Unfortunately, both methods may lead to an unsightly graft of scar in the area of treatment. When we decide to graft the face, we make a decision of whether to cover the face with a temporary cover, either allograft or a dermal substitute, prior to autografting. For the massive burn, we will use a temporary cover since the first donor sites are used for the hands and arms. When we graft the face, we do our best to follow esthetic units when placing seams.^8,9 We have developed the technique of harvesting a “U-shaped” donor site that essentially matches the shape of the face. Using a 6-inch wide dermatome, we harvest skin in a circular fashion so that one piece of donor skin can be wrapped around the entire face—thus minimizing seams.^2,3 One could argue that placing multiple grafts on the face that still maintain esthetic units is just as acceptable as one large circular piece. We find that having essentially one seam still leads to excellent results. We were not able to perform a long-term cosmetic evaluation of our patients since our institutional review board required that we obtain consents from every patient. In this retrospective review, this evaluation was not possible.

CONCLUSION

Face burns occur in around one third of patients admitted to burn centers. Fortunately, only a small percentage of those admissions require skin grafting. Most face burns, at least in adults, are caused by flames. The use of accelerants is a common and potentially preventable cause of these burns. The goal of treatment should always be to minimize scarring. Allowing the burn to heal within 2 weeks tends to minimize scarring. When grafting is needed, matching the donor site to the recipient site, using a “U-shaped” harvest, will further reduce scarring.

Funding: None declared.

Conflict of interest statement. None declared.

REFERENCES