Burn surgery specifics: large wounds and burns to the face and hands
Much of the information about burn wound surgery can be applied broadly, but there are some specific requirements for high percentage TBSA (total body surface area) burn wounds and burns to the face and hands.
High percentage TBSA burn wounds
Wound care prior to surgery
Topical treatment with Cerium nitrate silver sulphadiazine (Ce-SSD) can reduce mortality and morbidity in severely burned patients with extensive burn wounds that cover >20% of TBSA.
Cerium nitrate is a (lanthanide) metal that decreases the production of endotoxins and the release of inflammatory mediators. It also forms firm layer of cerium nitrate, which makes excision easier.
For burn wounds covering <20% of TBSA, treat initially with SSD. Once the eschar has resolved, change treatment to antiseptics such as Fusidic acid, mupirocin or povidone-iodine.
Staged burn wound excision and skin grafting
Staged excision is an appropriate option for burns covering a large percentage of TBSA.
Tangential excision causes massive blood loss, limiting the percentage of TBSA that can be excised. However, staged grafting enables a burn wound to be excised over multiple surgeries, limiting the peri-operative risks.
Staged grafting is also an appropriate option when large areas of eschar are excised and limited donor sites are available. It is possible to close the burn wound over multiple surgeries, and the graft can therefore be harvested from the same donor site again after healing. Between surgeries, the wounds are temporarily covered with allografts. If these are unavailable, an alternative is local wound dressing using topical antimicrobials.
The main disadvantage of this method is that it is time consuming. Wound colonization or even infection may occur in the meantime, delaying wound healing and resulting in more severe scarring.
It is not possible to accurately diagnose the depth of a face burn wound until at least 10 to 14 days post-injury, or as long as 3 weeks for the forehead.
Continuing conservative treatment rather than performing surgery often results in a better scar outcome. If a deep full thickness burn persists beyond the timeframe for accurate depth diagnosis, consider excision and skin grafting.
Before performing excision and skin grafting of the face, first excise and graft other large areas of the burn. Make a suitable donor site available, preferably the scalp, to ensure the outcome of grafting is more favorable than continuing with conservative treatment after 14 days.
When treating facial burns, do not mesh the graft, due to the ‘honeycomb’ effect that it creates. After excision, you can choose to cover the wound with a temporary skin substitute for 24 to 48 hours. This enables hemostasis and may improve graft take.
Burns to the hands
In cases where there are extensive burns that include the hands, first excise and graft the larger burn areas to optimize the patient’s survival. Hand burns can then be excised and grafted. However, it is vital to restore hand function for the patient’s daily activities and quality of life.
The patient may require an escharotomy as an emergency procedure. The timing of surgery depends on the extent of the burn. In isolated, full thickness burns, perform early excision and grafting. Also promote early exercising to keep the hand in motion to prevent contractures.
In cases with extensive burns, minimize surgery for hand burns (until large areas of the burn at other locations have been grafted). Instead, focus on internal (K-wire) splinting, external splinting and/or physical therapy, to preserve the range of motion.
Timing of the surgery then depends on the donor sites remaining and condition of the patient. Do not wait longer than necessary.
In very deep burns (partial) amputations may be unavoidable.
The skin on the dorsal side of the hand is thin and vulnerable to deep burns. On the volar side, the skin is thicker and stronger. You can therefore allow a longer period to await re-epithelization in this area.
Meticulous cleaning, debridement and, when the wound bed is ready for grafting, proper positioning and fixation of grafts are required to optimize the healing process. You may use K-wires for positioning and fixation of the fingers. An adequate post-operative dressing technique with Vaseline gauzes will provide the correct pressure required to secure the grafts and to protect them against shearing forces that may damage the fragile new skin. As soon as the grafts show good take, start exercises to keep the fingers mobile.