Head and Neck Burn Injury  CHAPTER 28 723

FIGURE 28-6  Burn assessment—the rule of

nines. (From Veenema TG: Handbook for
disaster nursing and emergency
preparedness, ed 2, St. Louis, 2009,
Mosby.)

Burn Size
The Rule of Nines.  To approximate the percentage of TABLE 28-3  Lund-Browder Chart
burned surface area, the body has been divided into
eleven sections: head, right arm, left arm, chest, abdomen, AGE (YR)
upper back, lower back, right thigh, left thigh, right leg Area 0-1 1-4 5-9 10-15 Adult
(below the knee), left leg (below the knee). Each of these Head 19 17 13 10 7
sections takes about 9% of the body’s skin to cover it. Neck 2 2 2 2 2
Added all together, these sections account for 99%. The
Ant. trunk 13 17 13 13 13
genitals make up the last 1% (Fig. 28-6). This rule is rela-
tively accurate in adults, but inaccurate in children. In Post. trunk 13 13 13 13 13
children, the Lund-Browder chart is the recommended R. buttock 2 12 2 12 2 12 2 12 2 12
method because it takes into account the relative per- L. buttock 2 12 2 12 2 12 2 12 2 12
centage of body surface area affected by growth (Table Genitalia 1 1 1 1 1
28-3).11 In small burn injuries, the extent of injury can R.upper arm 4 4 4 4 4
be quickly estimated because the palm of a patient’s L. upper arm 4 4 4 4 4
hand represents approximately 1% of the TBSA.
R. lower arm 3 3 3 3 3
L. lower arm 3 3 3 3 3
MANAGEMENT R. hand 2 12 2 12 2 12 2 12 2 12
L. hand 2 12 2 12 2 12 2 12 2 12
INITIAL ASSESSMENT R. thigh 5 12 6 12 8 12 8 12 9 12
The initial evaluation includes assessing for evidence of L. thigh 5 12 6 12 8 12 8 12 9 12
respiratory distress and smoke inhalation injury, evaluat-
R. leg 5 5 5 12 6 7
ing cardiovascular status, looking for other injuries, and
determining the depth and extent of burns. Initial assess- L. leg 5 5 5 12 6 7
ment for the burn occurs concomitantly with the burn R. foot 3 12 3 12 3 12 3 12 3 12
resuscitation. L. foot 3 12 3 12 3 12 3 12 3 12
Adapted from MacAfee KA II, Zeitler DL, Mayo Kathleen: Burns of the
CRITERIA FOR HOSPITAL ADMISSION head and neck. In Fonseca RJ, Walker RV (eds): Oral and maxillofacial
The initial problem in the management of a patient with trauma, Philadelphia, 2007, Saunders, pp 949–966.
thermal injury is to determine whether it is advantageous
to admit the patient to the hospital or whether he or she
724 PART IV  Special Considerations in the Management of Traumatic Injuries
can be safely treated as an outpatient. Table 28-1 shows
the indications for referral to a burn center when meeting
the criteria for a major burn. The following burn patients
are usually considered for admission:
1. Partial-thickness and full-thickness burns totaling
>10% TBSA in patients younger than 10 or older
than 50 years
2. Partial-thickness and full-thickness burns totaling
>20% TBSA in other age groups
3. Partial-thickness and full-thickness burns involving
the face, hands, feet, genitalia, perineum, or major
joints
4. Full-thickness burns >5% TBSA in any age group
5. Electrical burns, including lightning injury
6. Chemical burns
7. Inhalation injury
8. Burn injury in patients with preexisting medical dis-
orders that could complicate management, prolong
the recovery period, or affect mortality
9. Any burn with concomitant trauma (e.g., fractures)
in which the burn injury poses the greatest risk of
morbidity or mortality. If the trauma poses the
greater immediate risk, the patient may be treated
initially in a trauma center until stable before being
transferred to a burn center. The physician’s deci-
sion should be made with the regional medical
control plan and triage protocols in mind.
10. Burn injury in children admitted to a hospital without
qualified personnel or equipment for pediatric care
11. Burn injury in patients requiring special social,
emotional, and/or long-term rehabilitative support,
including cases involving suspected child abuse21
PREHOSPITAL CARE
Eliminating the Heat Source
Eliminating the heat source is the single most important
action to be taken at the scene of the injury. The involved
clothing should be removed, as well as rings, watches,
and other jewelry. Cooling and/or neutralization with
water or water gel dressing may also be appropriate to
stop the initial burning process; however, once the heat
source has been removed, cooling is no longer of benefit
and may result in significant hypothermia and peripheral
vasoconstriction that can extend thermal damage.
Cooling cannot halt the process of burning through the
physical skin barrier, but there is some evidence that
decreasing the amount of the prostoglandins and lessen-
ing the inflammatory process around the damaged zone
is helpful.26,27 Chemical burns should be copiously irri-
gated with water; however, dry chemicals should be gently
brushed off the skin before irrigation is begun.
Airway Management and Oxygen Administration
Patients with upper airway burns should be intubated
early, before airway anatomy becomes distorted by edema.
Soot in the mouth, facial burns, and body burns may be
more useful predictors of inhalation injury than symp-
toms of stridor, hoarseness, drooling, and dysphagia.28
Any patient rescued from a burning building or exposed
to a smoky fire should be placed on 100% oxygen via a
non–rebreathing mask if there is any suspicion of smoke
inhalation in awake patients.29
FIGURE 28-7  Patient with high suspicion of inhalation injury with
perinasal and perioral burns from a house fire. Bronchoscopy is
mandatory. (From Ward Booth P, Eppley B, Schmelzeisen R:
Maxillofacial trauma and esthetic facial reconstruction, ed 2,  
St. Louis, 2012, Saunders.)
Fluid Replacement
Emergency medical personnel should place an IV line
and begin fluid administration with lactated Ringer’s
(LR) solution at a rate of approximately 1 liter/hr in the
case of a severe burn; otherwise, a maintenance rate is
appropriate assuming there is no concomitant nonther-
mal trauma.21
HOSPITAL CARE
Inhalation Injury
Inhalation injury is the most common cause of death in
the burn patient30 (Fig. 28-7 ). Burn lesions larger than
70% of TBSA increase the risk of inhalation injury.31
Upper airway edema can rapidly occur and distort the
normal anatomy of the airway tracts. In the absence of
hypoxia, there is no definitive tool to assess whether
inhalation injury has occurred.32 Given the progressive
nature of burn injury in the first 48 hours, it is preferable
to secure an airway early. Any patient with deep facial or
intraoral burns, facial or upper airway edema, or sus-
pected inhalation injury should be considered for early
oral or nasotracheal intubation before edema causes
airway compromise. There is some evidence for using
aerosolized heparin and N-acetylcysteine to remove bron-
chopulmonary casts and reduce edema.33
Carbon Monoxide Toxicity.  Carbon monoxide (CO) is a
tasteless, odorless, and colorless gas present in the smoke
of the combustion of organic materials, such as wood,
coal, and gasoline. Because CO has a 200 to 300 times
greater affinity to stay bound to hemoglobin than oxygen,
the oxygen-carrying capacity of hemoglobin is reduced.
The clinical findings of CO toxicity are highly variable
and largely nonspecific. Symptoms and signs may include
headache, nausea, malaise, altered cognition, dyspnea,
angina, seizures, cardiac dysrhythmias, heart failure,
and/or coma. The presence of bright, cherry red lips is
an insensitive indicator of CO poisoning.34 Pulse oxime-
try is an unreliable tool in measurement of the oxygen
saturation in CO toxicity. Monitoring of the end-tidal
CO2 using capnography and assessing arterial blood gas
levels can help determine the efficacy of the primary

resuscitation care.35,36 An electrocardiogram (ECG) is
also obtained to assess for cardiac dysfunction.
Fluid Resuscitation.  A burn is a dynamic wound. Cyto-
kines enter the circulation when the burn reaches 20%
of TBSA and results in a systemic inflammatory response.37
Prostaglandins and leukotriene cause leaking of the fluid
and protein to the interstitial tissue, so cardiac output
decreases and burn shock occurs. Peripheral vasocon-
striction happens due to the sympathetic response
leading to conversion of the zone of stasis to the zone of
necrosis. Children younger than 2 years with more than
5% and any patient with more than 15% body surface
area (BSA) burns will require IV fluid therapy.5 In patients
with major burns, an IV line should be placed through
nonburned skin. Overadministration of fluids and elec-
trolytes can lead to pulmonary edema, peripheral edema,
and compartment syndrome.35 The Parkland (also known
as Baxter) formula is the most widely used guide to
administer fluid in burn patients.38,39 According to this
formula, the fluid requirement during the initial 24
hours of treatment is 4 mL/kg of body weight for each
percent of TBSA burned, given IV.40 Superficial burns are
excluded from this calculation. Half of the calculated
fluid needed is given in the first 8 hours and the remain-
ing half is given over the subsequent 16 hours.41
Another formula for resuscitation of burn patients is
the modified Brooke formula, which recommends
administering 2 mL/kg of body weight for each percent
of TBSA.35,42,43 The modified Brook formula lessens
edema formation and decreases the incidence of pulmo-
nary complications in those with preexisting cardiopul-
monary disease. To avoid overhydration, resuscitate
patients with a urinary output in the range of 1 to 2 mL/
kg/hr for children less than 30 kg and 0.5 to 1 mL/kg/
hr for those weighing 30 kg or more.44,45 Peripheral
pulses should be checked regularly, especially in limbs
with a circumferential burn, to determine whether there
is distal perfusion. Pulse rates are not very useful as a
guide to resuscitation because tachycardia with a rate of
100 to 120 beats/min is common in even adequately
resuscitated patients. Capillary refill may also be useful
in assessing adequate distal limb perfusion.46
Tetanus Consideration
Tetanus immunization should be administered to chil-
dren with burns deeper than superficial-thickness burns
who have not received booster immunizations in more
than 5 years.35
Pain Control
Although thermal injuries are usually extremely painful,
burn patients frequently do not receive analgesia in the
emergency department.47 In small burn injuries, empiri-
cal analgesic therapy is with nonsteroidal anti-
inflammatory drugs (NSAIDs) and, in larger burn
injuries, a combination of an opioid and NSAID can be
useful.48
Gastrointestinal Interventions
Shock from thermal burn injuries results in mesenteric
vasoconstriction predisposing to gastric distension,
ulceration (so-called Curling’s ulcer), and aspiration.
Head and Neck Burn Injury  CHAPTER 28 725
Therefore, a nasogastric tube should be placed in patients
with burns more than 20% TBSA.35,49,50
PRIMARY BURN WOUND MANAGEMENT
Traditional management of the burn wound involves
careful débridement of loose necrotic tissue, gentle
cleansing of the wound with a bland soap, and applica-
tion of dressings.51 Burn wounds should initially be
cleaned with mild soap and water. Disinfectants are typi-
cally avoided because they may inhibit normal wound
healing. Clothing and debris that are embedded in the
wounds should be removed. Débridement of devitalized
tissue (including ruptured blisters) decreases the risk of
infections.35 Needle aspiration of blisters should be
avoided, because this increases the risk of infection.49,52-54
A variety of proteolytic enzymes, such as collagenase, has
also been used for débridement of burn wounds.55,56
Wound Dressing
Superficial burns, especially minor burns in the face, do
not require dressings and treatment consists of gentle
cleansing with a mild soap followed by the application of
a topical agent.49 For patients who are being rapidly
transferred to a burn unit, burns should be covered with
dry sterile dressings.35
Topical Antibiotics.  The goal of therapy is not to steril-
ize the wound but to control bacterial density and
decrease the likelihood of burn wound infection. Early
administration of systemic antibiotics to prevent burn
wound infection is of little or no benefit and therefore
is not recommended. This practice is ineffective in reduc-
ing morbidity and mortality and is likely to promote the
rapid emergence of resistant microorganisms.57 There is
no consensus on which topical antimicrobial agent or
dressing is best suited for burn wound coverage to
prevent or control infection.58 They are generally divided
into potent agents used to prevent burn wound invasion
(e.g., silver sulfadiazine, mafenide acetate, silver nitrate)
and milder agents (e.g., bacitracin, Neosporin, Polyspo-
rin, mupirocin) used to treat small or superficial wounds.
The more potent agents may delay epithelialization and
should be reserved for use in managing more extensive
and deeper burns. The milder agents, when used in com-
bination with nonadherent gauze, provide a comfortable
protective environment that promotes epithelialization
of the wound.
Silver-Containing Dressings.  Silver-containing dress-
ings slowly release silver into the wound. Activated silver
has broad spectrum antimicrobial activity and may also
have an anti-inflammatory benefit.59 Silver nitrate solu-
tion (0.5%) is an effective agent but has decreased in
popularity over the past 2 decades. It is painless on appli-
cation, has a wide spectrum of antimicrobial activity, and
has no known bacterial resistance. Its use is limited due
to its staining, requirement for greater nursing care, and
the leeching of electrolytes from the wound. Paraffin
gauze over a silver-based dressing was shown to be effec-
tive in superficial burns.60
Silver Sulfadiazine.  Silver sulfadiazine cream (SSD) is
the most commonly used topical agent for dressing.58 It
is bacteriostatic but poorly diffusible and limited in its
penetration of the burn wound. It is painless on
726 PART IV  Special Considerations in the Management of Traumatic Injuries
application and has a soothing effect. The antimicrobial
spectrum of SSD includes Staphyloccus aureus, Escherichia
coli, Enterobacter, and Candida albicans.46 Transient leuko-
penia has been reported in up to 5% of patients; this
usually resolves spontaneously, even with continued use
of the drug.61 SSD should not be used in women who are
pregnant or breastfeeding, or in infants younger than 2
months.56,62
Chlorhexidine.  Chlorhexidine gluconate, a long-
lasting antimicrobial skin cleanser, is often used with a
gauze dressing for burn wound coverage in superficial
partial-thickness burns. Chlorhexidine dressings do not
interfere with wound reepithelialization, in contrast to
silver sulfadiazine.56
Mafenide Acetate.  Mafenide acetate (MA) cream is
bacteriostatic, freely soluble, and readily diffuses through
burn eschar to the viable tissue interface. This agent also
has the broadest spectrum against Pseudomonas spp. and
gram-negative organisms. MA inhibits protein synthesis
in P. aeruginosa. Up to 90% of the dose enters the wound
within 5 hours and it reaches peak concentration within
1 to 2 hours. Its concentration decreases to subinhibitory
levels within 10 hours; therefore, it must be applied at
least twice daily.46 The principal limitations of this agent
are the pain produced when applied to partial-thickness
wounds and the inhibition of carbonic anhydrase that
predisposes to the development of metabolic acidosis.
Use of this agent is generally limited to wounds with or
at high risk for invasive infection.56,63
Biosynthetic Dressings.  Tissue engineering has pro-
gressed in the last decade and can now be applied for
the replacement of injured tissue. Bioengineered skin
dressing, also called semibiologic skin substitute, is used
to increase the healing potential of the recipient bed and
decrease the number of dressing changes.56,64 Biobrane
and Integra have been recognized by the U.S. Food and
Drug Administration (FDA) as wound dressing materials.
Both substitute as a matrix-like structure for harvesting
fibroblasts and forming collagen. Following the activity
of the fibroblast cells, the endothelial cells can also
promote vasculogenesis, which can help with manage-
ment of the partial-thickness burn.
Escharotomy
Mechanical obstruction of the airway, as well as distal
tissue compartment syndrome, can occur due to the
eschar formation in the neck and chest area. Releasing
incisions during primary wound management can help
provide distal tissue pressure that does not exceed 30 mm
Hg.35,65
SECONDARY BURN WOUND MANAGEMENT
Full-thickness or partial-thickness burns that fail to heal
within 3 weeks should be excised and treated with graft-
ing. An early appropriate decision for the burn excision
and grafting can lead to shorter hospitalization and fewer
complications.66 If early excision and grafting is the treat-
ment of choice, it may be a one- or two-stage technique.
With the one-stage technique, the operation consists of
excision of the burn to viable tissue and the placement
of a graft. In the two-stage technique, the first operation
is for the excision of the burn to viable tissue and
coverage with a biologic dressing. The wound is reevalu-
ated and grafted 24 to 72 hours later.67 Critical areas must
be grafted first to achieve optimal functional and cos-
metic results. Blood loss is a major consideration in exci-
sional therapy. In adults, approximately 200 mL of blood
is lost per percentage of TBSA excised and grafted.68 In
children, blood loss is approximately 3% to 4% of the
circulating blood volume per percentage of TBSA excised
and grafted.69 Following burn wound excision, skin grafts
are applied to the viable tissue bed. Split-thickness skin
grafts are harvested with a dermatome at a depth of 0.008
to 0.016 inch (0.2 to 0.4 mm). For small burns, full-
thickness skin grafts (with primary closure of the donor
site) should be used because they result in minimal
donor site morbidity and excellent long-term functional
and cosmetic results. For larger burn defects, meshed or
nonmeshed split-thickness skin grafts can be used. Allo-
genic cadaveric skin from a human tissue bank also
would be an option for a total-body burn patient for
whom additional donor site for grafting is not available.
TransCyte is a cultured epidermal autograft produced by
culturing dermal fibroblasts onto a synthetic scaffold,
which consists of a mostly nylon mesh. Skin fragility and
susceptibility to infection are the disadvantages.56
Facial Burns
The head and neck area is the anatomic site most fre-
quently involved in burn injuries. Facial burn injuries can
produce devastating cosmetic and social alterations,
which can affect self-image and societal perception.
Marked edema can develop with partial-thickness burns
in the face due to the looseness of the tissue and rich
blood supply. Inhalational injuries should be suspected
in any facial burn. The basic principles of grafting pro-
cedures performed on the head and neck must include
the importance of aesthetic facial units. When grafting is
undertaken, replacing an entire aesthetic unit is indi-
cated, rather than applying grafts in patches.70 Skin grafts
to the face are thicker than those used elsewhere in the
body to provide less contracture; they are not meshed to
enhance aesthetics.71 Grafting of the face is done by aes-
thetic region and every effort should be made to recon-
struct the dermatologically defined facial units, including
the forehead, eyebrows, upper eyelid, lower eyelid,
cheek, upper lip, lower lip, and chin. Immobilization of
the graft by pressure dressings, nasogastric feedings, and
avoidance of speaking are essential.46 Donor sites of good
quality for the face are the scalp, neck, supraclavicular
region, and inner thigh or arm.67 Flame or contact burns
in the head and neck may occur concomitantly with
facial trauma in MVAs (Fig. 28-8).
Eye Burn Injury
Chemical burns of the eye constitute ocular emergen-
cies. Acid burns of the eye are much better tolerated than
alkali burns, which may result in injury ranging from
mild corneal erosions to severe and generalized eye
burns that manifest as blurring of the pupil and blanch-
ing of the conjunctiva and sclera.14,71,72 The initial treat-
ment is copious irrigation with normal saline. Staining of
the eyes with fluorescein is performed to detect corneal
injury. If corneal abrasion is present, a topical antibiotic

FIGURE 28-8  Facial burn associated with maxillofacial trauma.
is prescribed. The main complications of chemical burns
of the eye are symblepharon and corneal ulceration.
Eyelid Burn
The eyelid as a protector of the globe may be involved
in most burn injuries of the face (Fig. 28-9). The eyelid
has the thinnest skin on the face, which makes it suscep-
tible to early contracture and exposure of the cornea. An
ophthalmologist should be consulted because corneal
abrasion and exposure keratitis are the most common
associated sequelae. An early grafting with tarsorrhaphies
should be considered in management of the eye burn.
In severe full-thickness eyelid burns, the globe can be
protected by the raising and closure of the upper and
lower conjunctival flaps, which are then covered by a skin
graft. Split-thickness grafts for the upper lid and full-
thickness grafts for the lower lid are generally indicated.73
With superior lid débridement, one should be aware of
the levator musculature and possible lid ptosis. The most
common complication of eyelid burns is contracture and
the development of ectropion.
Brow Burn
A number of reconstructive techniques are available for
full-thickness brow burns, including punch grafts, single-
hair transplants, temporal vessel-based scalp flaps, and
composite hair- bearing scalp grafts. The composite scalp
graft should be no wider than 3 mm in a vascularly com-
promised bed. Multiple strips can be grafted and the
intervening skin excised after healing. The procedure
can be performed under local anesthesia, with good
success.74,75
Ear Burn Injury
Lack of subcutaneous tissue, thinning of the skin, and
lateral prominence of the ear can aggravate the severity
of the burn in this area (Fig. 28-10). Direct injury to the
Head and Neck Burn Injury  CHAPTER 28 727
A B
C D
FIGURE 28-9  In severe full-thickness eyelid burns, the globe can
be protected by the raising and closing of upper and lower
conjunctival flaps, which are then covered by a skin graft.  
A, Outline of conjunctival flaps. B, Sharp elevation of conjunctival
flaps. C, Suturing upper and lower conjunctival flaps together for
corneal coverage. D, Vascularized conjunctival bed for skin graft
placement. (From Ward Booth P, Eppley B, Schmelzeisen R:
Maxillofacial trauma and esthetic facial reconstruction, ed 2,  
St. Louis, 2012, Saunders.)
ear cartilage by burn and/or secondary infection can
lead to chondritis. The organisms most commonly
responsible are S. aureus and P. aeruginosa.76 Ear injuries
may need local débridement or resection, but a regimen
with minimum débridement and use of a topical antibi-
otic may be useful. Avoiding pressure on the ear is
another important aspect of primary management. If
chondritis occurs, it can be managed by removal of the
affected cartilage. Attempts to salvage viable cartilage
may be made by burying cartilage in soft tissue pockets
and later performing secondary graft reconstruction.
Some patients may require local regional temporalis
fascia flaps for coverage. Denuded cartilage can be
covered by skin grafts or local cutaneous advancement
flaps from the retroauricular region. Flaps are elevated
in the supraperichondrial plane. Small segments of non-
viable cartilage can be removed without altering aesthet-
ics. Larger defects may need to be reconstructed with a
composite graft.46,77 For total ear reconstruction, the use
of osseointegrated implants and prosthesis is probably
the best treatment.78
Nasal Burn Injuries
The nose has a prominent feature in the face and burn
injuries are common. The thick skin on the lower portion
of the nose can provide some protection to this area, but
the skin across the lateral aspect and bridge of the nose
728 PART IV  Special Considerations in the Management of Traumatic Injuries

D E

FIGURE 28-10  Partial-thickness ear burns. A, Superficial partial-thickness ear burn 3 days after injury. B, 3 months postinjury with
spontaneous healing. C, Deeper part-thickness ear burn on admission. D, Complete healing by 1 month after injury. E, Combination
partial and full-thickness ear burn 3 days after admission. (From Ward Booth P, Eppley B, Schmelzeisen R: Maxillofacial trauma and
esthetic facial reconstruction, ed 2, St. Louis, 2012, Saunders.)

is thin.72 Generally, the nose is allowed to heal by spon-
taneous epithelialization. A deep partial-thickness burn
defect of the nose requires a full-thickness skin graft.
Maintaining skeletal cartilage support is an essential
factor for the optimum aesthetic result. Auricular carti-
lage provides a contoured graft material and costochon-
dral rib grafts also may be sculpted.46 Nasal injuries can
be devastating and hard to reconstruct. Flattening of the
alar region is often encountered secondary to contrac-
ture. Intraoral flaps, because of their proximity, can be
used in reconstruction of the lower third of nose struc-
tures.79 Providing a vascular bed in scar recipient sites can
increase the viability of the composite graft (Fig. 28-11).
Scalp Burn Injuries
Scalp burns are often partial-thickness burns due to the
thickness of the skin in this anatomic area and deep
placement of the hair follicles. Split-thickness skin grafts
can be used in partial-thickness injuries. Rotational flaps
or tissue expansion can be part of the treatment plan in
 Head and Neck Burn Injury  CHAPTER 28 729

A B

C D
FIGURE 28-11  A, Depressed lower left alar rim due to a previous burn. B, Pedicle rotational intraoral flap for reconstruction of the
avascular bed. C, Suturing of the helical composite graft over the mucosal flap. D, 12-month follow-up of the patient. (Courtesy
Dr. F. Pourdanesh, Shahid Beheshti University of Medical Sciences, Tehran, Iran.)

a highly aesthetic area. Perforation of the cortical bone
for the appropriate vascularization can help in better
survival of the flap. In severe burns, removal of the outer
table of the cortical bone is an alternative option. Tech-
netium bone scans can be used to show a lack of perfu-
sion in areas of nonviable bone and increased uptake in
areas of bone sequestration and regeneration.71,80
Mouth Burn Injuries
Burns that involve one or both lips can lead to severe
microstomia. Hypertrophic scars in this area lead to dif-
ficulty in eating or intubation of the burning patient.
Oral splinting devices should be fabricated and inserted
as soon after the burn as possible. In a child, the appli-
ance conforms to the teeth and stabilizes the commissure
by an attached horizontal bar. Adults are generally more
cooperative and will wear a mouth splint, such as the one
depicted in Figure 28-12.81 The most frequently encoun-
tered burn injury in children is an electrical burn injury.
Electrical burns of the mouth predominate in 1- to 2-year-
old children and generally result from putting the socket
terminal of an extension cord into the mouth or sucking
on the wall socket.82 The tongue, lower and upper lips,
and commissures all may be affected.14,83 The oral
commissure burn deserves special mention because it is
not uncommon and is easily treated. Typically, the burn
area is sharply demarcated and the eschar is separated
slowly. Conservative treatment with an orthodontic
appliance to avoid microstomia is the first step. The
second step would be correction of the scar, especially
in the vermilion border. Upper and lower lip grafts
can be placed to reconstruct the vermilion. Mucosal
advancement flaps can also be used. Later, secondary
reconstruction may be necessary, including scar-releasing
procedures.
See Figures 28-13 to 28-18 for illustrations of repair of
various facial burn injuries.
SUMMARY
Complex burn reconstruction requires all the skills of
the facial reconstructive surgeon. In the acute phase,
patients frequently have concomitant medical and meta-
bolic abnormalities requiring a team approach for com-
prehensive treatment. Burn patients are ideally treated
in centers dedicated to burn care. Oral and maxillofacial
surgeons are an essential part of the burn team for facial
and oral reconstruction.
730 PART IV  Special Considerations in the Management of Traumatic Injuries

FIGURE 28-12  Custom-made device for the inhibition of the microstomia

following burn.

FIGURE 28-13  A, Patient not happy with lower

face skin graft and would like to have a
B
beard. B, Bilateral rotational scalp skin graft.
 Head and Neck Burn Injury  CHAPTER 28 731

FIGURE 28-13, cont’d C, Final postoperative

result after a few months. D, Preoperative
and postoperative views of vertex.
D
(Courtesy Dr. Hossein Haghshenas.)

FIGURE 28-14  Almost total facial burn, including neck, midface, lower face, and right ear. (Courtesy Dr. Hossein Haghshenas.)
FIGURE 28-15  Multiple facial reconstruction
with skin graft and forehead flap for nasal
reconstruction. (Courtesy Dr. Hossein
Haghshenas.)

FIGURE 28-16  A, Application of tissue

expander at left neck for reconstruction of
lower face burn. B, Postoperative
photograph. (Courtesy Dr. Hossein
B
Haghshenas.)

FIGURE 28-17  Double tissue expander application for
reconstruction of a scalp burn. (Courtesy Dr. Hossein
Haghshenas.)
FIGURE 28-18  Total facial reconstruction, including nose, facial soft
tissue, lower lip and right brow graft. (Courtesy Dr. Hossein
Haghshenas.)
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