Face, 5 year-old
This case study involves a 5-year-old boy who sustained burn wounds to the face, right arm, and chest. The focus of this case is the treatment of his facial burn injuries. The patient was treated at Haydom Lutheran Hospital in Tanzania, a tertiary care hospital. It illustrates the importance of making informed decisions about where to begin with grafting when patients are not able to undergo grafting for all affected areas at once. It also highlights the importance of making the right choices when multiple surgeries are not an option due to cost.
To learn more about how his arm burn injuries were treated, see Arm.
Medical history
The patient sustained burn injuries while trying to remove his clothes that caught fire while he was playing near a traditional wood stove. He was brought to the hospital two days after the injury. The patient's initial caretaker was his grandmother, but she left shortly after admission. The patient's uncle was then contacted and agreed to take on the role of caretaker after being counseled. Due to living 250 kilometres away from the hospital, the uncle did not arrive until two weeks after the initial phone call.
Physical examination
Upon examination, the doctors observed that the patient had dry and leathery burn wounds. Two days after the injury, the forehead showed eschar formation, particularly on the left side. There was no capillary refill and sensation was absent in the affected areas. The wounds on the nose, chin, and left cheek were determined to be superficial and showed good capillary refill. The right side of the chest and right arm, including the elbow and wrist, were affected by deep burns. The total body surface area affected was 13%. There was no indication of inhalation injury after reviewing the patient's medical history and performing a physical examination.
Conservative management
During the patient's early days of admission, supportive treatment was provided through fluid administration, closely monitored by measuring urinary output. Pain relief was achieved through the use of paracetamol and diclofenac during wound dressing. The face wounds were treated by daily soaking and dressing with silver sulfadiazine (SSD) for one week. The SSD helped to soften the wounds, allowing for the removal of loose eschar on a daily basis. The wound showed different features, which indicated different depths and healing potentials. On the seventh day after the burn, parts of the eschar still remained, particularly on the left side of the forehead (as seen in Photo 4). On the eighth day post-burn, the eschar was removed thanks to the softening effect of SSD, allowing for an estimation of the wound depth. On the forehead, right eyelid and cheek, there were no signs of re-epithelization (as seen in Photo 5).
Surgery
Surgical considerations
In this case, the doctors chose to take a staged, delayed approach to grafting. The first stage included the face and right arm, while the chest was addressed in the second stage. The reason for this was because performing surgery on all three areas in one session was deemed too demanding for the child due to the potential for blood loss and pre-operative anemia (Hb 8 gr/dl). The first surgery was performed on the 12th day after the initial injury. At this time, superficial dermal burns may have started to heal, and deeper dermal burns may have begun to show signs of healing potential through the growth of epithelial buds. However, in this patient, no signs of epithelialization were observed in the wounds (as seen in Photo 6).
Preoperative care
Due to the patient's anemia and the anticipation of blood loss during surgery, the patient received one unit of full blood prior to the procedure.
Surgical procedure
The burn wounds on the face and right arm were cleaned surgically before the split-thickness skin grafts (SSGs) were applied. The lateral thigh was used as the donor site. To control bleeding after the grafting, a gauze soaked in an adrenaline solution was used. The SSG was not meshed when placed on the face, but a few incisions were made in the unmeshed graft to allow for drainage. Rapid absorbable sutures were used to fixate the grafts in place.
Postoperative care
After the surgery, tetracycline ointment was applied to the fresh grafts. They were then covered with a single layer of Vaseline gauze and a single layer of dry gauze. To prevent graft failure, it was important to minimize friction on the wounds. To achieve this, the patient and caretaker were instructed to avoid inspecting the wounds until the fourth day after surgery. Four days post-surgery, the grafts were observed to have taken well, and the wounds were not producing exudate. After that the grafts were kept undressed.
Outcome
Six weeks after surgery, the patient's skin on the face and arm had fully healed. There were no issues with range of motion in the wrist and elbow. However, the patient's caretaker had declined consent for surgery on the chest. At the time of discharge, the chest wound had decreased in size but still had large areas of hypergranulation.
One year after the burn injury, the patient had scars on the face and right arm. There was also some hyperpigmentation present on the face. Despite not receiving physiotherapy, the patient had no functional limitations. Unfortunately, as surgery on the chest had not been performed, a small wound remained on the chest.
Lessons learned
When it comes to facial burns, it's generally recommended to wait longer before undergoing grafting compared to other areas of the body. This is because the face tends to re-epithelize (grow new skin) later than other areas.
When performing a graft on the face, it's best to use an unmeshed split skin graft to avoid the honeycomb appearance that can occur with a meshed graft. If possible, it's also a good idea to use a donor site with similar skin tone, such as the scalp.
In children, small, fast-absorbable sutures are preferred for fixing the graft in place. This helps to minimize pain and the need for suture removal later on. If the graft takes well, the site can be left undressed after 4-5 days. However, in pediatric patients, it's important to consider the risk of friction caused by uncontrolled movements, so it may be necessary to keep the site dressed.
It's also important to keep in mind that socioeconomic factors may limit treatment options. In this case, it may be wise to start by grafting the areas that are most important to the patient, such as the arm and face.
