Resurfacing the burned face

Facial burns cause deformities through the permanent effects of wound contracture and scar hypertrophy; they are related to the depth of the burn. The depth of an acute burn can be accurately ascertained only by observation over a period of time. Facial skin burns that do not heal by three weeks are subject to increasingly permanent deformity with the passage of time. The best defense against wound contraction and hypertrophic scar is early and complete wound closure. Early and late grafting must be completely successful in "take" to avoid unsightly irregular scarring; therefore, the receptor bed must be meticulously prepared for optimal take. Both early and late grafts are patches that flatten normal contour. However, if the skin graft conforms to a position in the facial mosaic (aesthetic unit of the face), or some subunit that is harmonious with normal facial lines, the patch of proper color can give a more aesthetic result. Nonreproducible anatomical structures such as the margins of the lids, lips, and nostrils should be preserved whenever found to be normal or only partially destroyed. To minimize the distorting effects of wound contracture, pressure therapy of the face and neck, as well as the positional splinting of the neck, must be maintained for many months following grafting and epithelialization until the deleterious wound forces abate. Burns of mobile structures, such as lids and lips, do not lend themselves to control by pressure, and frequently must be managed secondarily by first totally removing scarred tissues and then applying thick skin grafts of the best color match.