A Ten-Year Experience With Pediatric Face Grafts

Transcription

1 A Ten-Year Experience With Pediatric Face Grafts David G. Greenhalgh, MD, FACS, Katharine Hinchcliff, MD, Soman Sen, MD, Tina L. Palmieri, MD The authors reviewed their 10-year experience of performing face grafts in children with burns. They sought to compare different methods for aesthetic outcome and need for reconstruction. In addition, they determined the efficacy of using allograft skin or Integra as temporary covers. They performed a review of 160 pediatric patients who underwent acute facial excision and grafting for burns between 2000 and Of the 160 patients with a mean age of 5.8 ± 4.8 years, 96 were males. The mean burn size was 39.4 ± 24.61%, of which 36.5 ± 25.4% was third degree. Overall length of stay was 72.1 days, intensive care unit length of stay was 44.2 days, and the mortality rate was 13.75%. Ninety patients had their entire face burned, 42 burned half, 15 burned their foreheads, and seven had other combinations. The interval between injury and grafting was 13.9 ± days. Sixty-three percent patients required one face graft, 23% had two, 8% had three, and 6% four or more. For their initial procedure, 105 patients underwent autografting, 28 had allografting, and 23 received Integra. The authors performed a two-stage procedure in 20.4% and a 1-day procedure in 79.6%. Ten patients had a contiguous U-shaped graft wrapped around the face. At least partial regrafting was performed in 21.1%. Allograft and Integra were used for massive burns (69.9 ± 14.5%, 62.6 ± 18.3%, respectively). Of these, 39% died, 17% developed an Integra infection, and 43% required regrafting before autografting. Overall, 24.5% of patients underwent facial reconstruction during their first admission, and 57.1% during subsequent admissions. No difference in the rate of reconstructive surgery was noted between patients receiving Integra or autografting. Autografting face burns as an initial, one-stage procedure works well. The wrap-around autograft leads to excellent cosmetic results. When there is a shortage of autograft, allograft or Integra are good options but Integra does not reduce the need for reconstructive surgery. (J Burn Care Res 2013;34: ) Deep burns to the face are some of the most difficult challenges for burn surgeons. Because the face is exposed to society any disfigurement is immediately noted. Even a minor facial scar is extremely difficult to disguise. Facial disfigurement in a child is even more challenging because peers often seek out differences as a way of teasing another peer. Scars to the face of a young child have the additional challenge of dealing From the Shriners Hospitals for Children Northern California, Sacramento; Firefighters Regional Burn Center at University of California, Davis; and Department of Surgery, University of California, Davis. Presented in part as a Poster at the 43rd Annual Meeting of the American Burn Association, Chicago, Illinois, March 31, Address correspondence to David G. Greenhalgh, MD, FACS, Shriners Hospitals for Children Northern California, 2425 Stockton Boulevard, Sacramento, California Copyright 2013 by the American Burn Association X/2013 DOI: /BCR.0b013e3182a22ea5 with growth because scars usually do not expand as fast as the underlying structures. 1 Although reconstructive procedures are helpful, they never eliminate scars. The best strategy is for the burn surgeon to aggressively treat the patient during the initial acute episode. Doing it right at the start reduces the need for future reconstructive procedures. There are various strategies that can be used to improve the outcomes of burns to the face in children and adults. Fortunately, the face has a better chance to heal without scarring than other areas. It is well-known that if a burn reepithelializes in around 2 weeks it rarely develop hypertrophic scars. 2 The face has a very abundant blood supply, and, because a more vascular tissue dissipates heat, the face can tolerate burns better than other parts of the body. It is also conceivable that the closeness of the facial skin to the many muscles (and less to fat) may improve its ability to tolerate burns. In addition, the face has 576

2 Volume 34, Number 5 Greenhalgh et al 577 a very high density of skin adnexa especially in the beard distribution, which improves reepithelialization. All of these factors give the face a better chance to reepithelialize rapidly and lessen the chance of scarring. Because of these issues many surgeons advocated decades ago that excision and grafting should be avoided in face burns. 3 5 Currently, grafting is the preferred strategy for dealing with burns that are clearly full-thickness or those that have not closed within 2 or, at most, 3 weeks. Several recent articles have described the techniques and outcomes of their surgical methods There are various choices as to whether one performs surgery in one stage (with immediate autografting) or two stages (initial placement of allograft, Integra [Integra LifeSciences, Plainsboro, NJ], or just covering the excised tissue with saline-soaked gauze). Many advocate for a two-stage approach to minimize the risk for postoperative hematomas or to ensure a viable wound bed. The type of temporary cover varies among the surgeons. All surgeons try to abide by the principles of placing any seams along the borders of aesthetic units. 11 We have also had a philosophy of performing early excision and grafting of obviously deep face burns. We tend to perform one-stage procedures for those patients with available donor skin. If a child has massive burns then we will excise the face within a week and then cover the excised face with allograft or Integra. We will then replace the temporary covering with autograft when donor sites are available. Several years ago we developed a technique of harvesting a U-shaped piece of donor skin so that the graft could be wrapped around the face to allow for only one seam. This article describes our experiences with these techniques for treating children with facial burns and compares outcomes of patients treated with one- or two-stage grafting procedures to determine whether one method led to better outcomes. The use of allograft or Integra was also evaluated. Finally, the need for early reconstruction was documented. METHODS We performed a chart review of 160 pediatric patients who underwent acute excision and grafting for face burns that occurred between 2000 and 2010 at the Shriners Hospitals for Children Northern California. The Shriners Hospitals is a quaternary referral hospital for children under the age of 18 years. The region that is covered includes all of the United States west of the Rocky Mountains, Western Mexico, and the Pacific Rim Islands, so we tended to admit very large burns. The retrospective review was approved by the Institutional Review Board of the University of California, Davis. Patients gave written permission for the use of pictures of their faces. Charts were reviewed for the usual patient characteristics and severity of burn. The type of surgery performed and time after injury were also determined. We recorded the type of temporary covering that was placed on the excised wounds if a two-stage procedure was performed. We also documented any graft failure and need for regrafting. The outcomes of the face grafts and the ultimate need for early contracture or ectropion release were documented. Values are expressed as mean ± SD. We performed χ 2 analysis to compare failure rates between one-stage and two-stage procedures. Surgical Technique We perform excision and grafting as soon as it is clear that the face burns will not heal within 2 weeks. For obviously deep burns we excise and graft the face within a few days of admission. For children with massive burns (>60% TBSA) we start excision and grafting on postadmission day 2. Typically, on day 2 we perform a tracheostomy, and then excise the extremities and anterior trunk. During the same procedure we cover as much of the excised tissue with autograft starting with the hands (using either sheet grafts or 1:1 mesh), and then use 4:1 mesh on the arms and legs as skin is available. The rest of the excised areas are covered with frozen allograft. On the next day we excise the back and cover it with any available donor skin (4:1 mesh) or allograft. On the third day, we excise the face and cover it with either allograft or Integra. The face will then be autografted when donor sites are available, which is often after other areas of the body are covered. For a deep face burn that has available donor sites we plan excision and grafting within a day or so after admission. We often perform tracheostomies on children (or adults) with extensive face burns to keep all ties out of the grafted areas. If we were of the opinion that the endotracheal tubes would not interfere with the graft and that prolonged intubation would not be necessary we would not perform tracheostomies. The planned donor site will depend on how much of the face is burned. If only part of the face is burned and there is enough skin available to cover the wound we will use the scalp. We agree with others that the color match is better from the scalp. Scalp donor skin, however, does have its problems. We try to harvest skin that is 12 to 15 thousandths of an inch thick to minimize contractures. This thickness may lead to some mild alopecia, and if the hair

3 578 Greenhalgh et al September/October 2013 is not removed, will lead to occasional hair transfer. Overall, alopecia was rare if the scalp was harvested once, and more common in patients with large burns requiring multiple reharvests of scalp skin. After the harvest, the dermal side of the scalp skin is scraped with the back of a pickup in attempt to remove as much hair as possible. Any remnant hair may lead to inclusions cysts or may become permanent hair. If the entire face is involved or if there is inadequate scalp donor site available we prefer to use the back because it can provide large pieces of skin and has less chance of scarring compared with the thighs. 12 The color match is irrelevant in the case of an entire face burn because there is no normal skin to contrast the color of the donor skin. During the study period we started harvesting skin in a circular or U shape in order to obtain a circular piece that could be wrapped around the face. The goal is to be able to wrap one piece around the entire face. With the advent of the 6-inch wide Padgett Dermatome (Integra LifeSciences) we have been able to cover any face (including adults) with this technique. After induction of anesthesia, the patient is positioned in slight reverse Trendelenburg position. The head and donor site of the patient are prepped and draped. When using the back for a donor site, we will often roll the patient on his/her side, prep the back, and then roll him/her back on the drape for later harvest. The subcutaneous tissue beneath the face burn is then injected with Pitken solution (lactated Ringer s solution containing 2 mg/l epinephrine) to reduce bleeding. Despite the epinephrine the burn team should be prepared for extensive bleeding. Housinger et al 13 demonstrated that a child will lose approximately 4.5% of a blood volume for each percent of face burn excised. Our experience supports this amount of bleeding so we often start a transfusion at the beginning of the excision. Hemostasis is completed with epinephrine-soaked gauze, topical spray thrombin, and the cautery. As others have stated, complete hemostasis is essential to prevent postoperative hematomas. The donor skin is harvested at approximately inch thickness in a circular or U fashion. If possible and appropriate, the 6-inch wide Padgett dermatome will provide skin wide enough for any sized person. The U-shaped donor skin is then wrapped around the face and stapled at the ends. The placement of the single seam varies dependent upon the fit of the skin but we always try to place it at the boundary of an aesthetic unit. We often suture the regions around the eyelids using a 5-0 plain gut suture. We usually do not perform tarsorrhaphies but we rinse the eyes with ph-balanced saline solution. Postoperatively, we leave the face open (no dressings) so that nurses or surgeons can watch for hematomas or seromas. Immediately after surgery, blood or serum is rolled out from under the skin. There is no special sedation for the children after surgery. They are provided narcotics and benzodiazepines but are allowed to eat and drink when extubated. As stated earlier, many of these children received tracheostomies for expected prolonged intubation but no special efforts were made to keep them from moving parts of their faces such as their mouths or eyelids. After a day, any new hematomas or seromas are drained by nicking the overlying skin to drain the fluid. We do not use any topical ointments. All grafts have their staples removed on day 5 and patients were allowed to eat or drink immediately after surgery (although children with extensive burns were often receiving enteric feedings). Once the grafts are stable (usually days) patients receive either topical silicone gel, soft face masks, or were casted for hard plastic masks. The description of the scar management of the face grafts in this study is published elsewhere. 14 The patients were also followed up for the development of any early contractures that could lead to significant morbidity. Upper and lower eyelid ectropia were the most common problems and they were treated with release with full-thickness skin grafting. Other complications of the face were also documented. RESULTS Between 2000 and 2010, 160 children admitted to the Shriners Hospitals for Children Northern California received split-thickness skin grafts to the face (Table 1). They had a mean age of 5.8 ± 4.8 (mean ± SD) years, and 96 (60%) were boys. Because the hospital treats large burns from Mexico, 108 (67.5%) were from that region, 49 (30.6%) were from the United States, and three were from other countries. Thus the ethnicity of the majority of patients was Hispanic (112 or 70%), whereas 16 (10%) were White, 11 (6.9%) African-American, 7 (4.4%) Asian, 2 (1.3%) Native American, and 12 were of unknown ethnicity. The cause of the face burn was mostly flame (134 or 83.8%), with scalding being the second most common cause (17 or 10.6%). There were three patients each who had electrical or contact burns to the face. Ninety patients (56.3%) had burns involving the total face, whereas 42 (26.3%) had at least half of the face injured and 15 (9.4%) had burns isolated to the forehead. The extent of severity of the injuries is indicated by the burns being 39.4% ± 24.6 (1 98%) TBSA and 36.6% ± 25.2 (0.5 98%) being full-thickness burns. Two thirds (105) received

4 Volume 34, Number 5 Greenhalgh et al 579 Table 1. Patient demographics Demographic Number of Patients Age 5.8 ± 4.8 yr ( yr) 160 Sex Males 96 Females 64 Country of origin United States 49 Mexico 108 Other countries 3 Race Hispanic 112 White 16 Black 11 Native American 2 Asian 7 Other 12 Burn type Flame 134 Scald 17 Electric 3 Contact 3 Other 3 Location Total face 90 Half of face 42 Forehead 15 Other 13 TBSA 39.4 ± 24.6% (1 98%) 160 % Full thickness 36.6 ± 25.2% (0.5 98%) 160 Values expressed as mean ± SD (range). tracheostomies whereas 55 did not. The mean length of stay in the intensive care unit was 44.2 ± 57.5 days and the patients required 32.3 ± 50.8 days on the ventilator. The overall length of stay was 72.1 ± 73.7 days, which is longer than the expected 1 day/% TBSA burn because patients from Mexico were kept for prolonged rehabilitation. Twenty-two patients (13.8%) died during their stay. The patients were admitted a mean of 3.9 ± 10 days after their injury (Table 2). The time from injury to face grafting occurred 13.9 ± days after injury. Some patients had their faces grafted 1 day after injury and there were three outliers with grafting occurring on days 55, 59, and 119. The median day of grafting the face was 11 days. The patient with a Table 2. Characteristics of the face grafting procedures Average interval, injury to admission 3.9 ± 10.0 days Average interval, injury to grafting 13.9 ± days Days for procedure Same day 79.60% Two day 20.40% Was allograft or Integra meshed Yes 35.29% No 64.71% Number of patients with U-shaped graft 10 Proportion of graft failures 21.10% Proportion of graft failure d/t infection 16.70% Table 3. Surgical details First graft procedure Second graft procedure Third graft procedure Fourth graft procedure Proportion of Patients 63% had one skin graft only 23% had two skin grafts only 8% had three skin grafts only 6% had four skin grafts only Graft Material No. of Patients Autograft 105 Allograft 28 Allo + autograft 1 Integra 23 Integra + allograft 1 Autograft 43 Allograft 15 Integra 1 Autograft 14 Allograft 5 Integra 2 Integra + allograft 1 Autograft 6 Allograft 3 graft at day 119 presented to the hospital after 97 days. During the first part of the study period a twostage procedure was performed where the face was excised, covered in saline soaks, and then returned to the operating room the next day for grafting. Overall, 20.4% of the patients had this two-stage procedure. We soon learned that the fat would dry out during the 24 hours and we would often have to reexcise the wound before grafting. Our practice thus switched to a one-stage procedure where excision and grafting were placed during the same procedure. Therefore, the majority of the patients (79.6%) had a one-stage procedure. Ten patients with total or near-total burns to the face (occasionally sparing the lips) had the wrap-around graft made out of a U -shaped piece of donor skin. Because some of the patients had allograft or Integra placed as an initial procedure, many patients had several procedures (Table 3). Overall, 63% of the patients had only a single graft performed. Twentythree percent had two grafting procedures and 8% had three and 6% had four grafting procedures. The material grafted during each of these procedures is revealed in Table 3. The majority of patients received autografting at each procedure. For the others there was roughly an equal amount of allograft and Integra used. Both the allograft and Integra tended to be used for patients with massive wounds (69.9 ± 14.5%, 62.6 ± 18.3% TBSA burns, respectively). One of the debates at the time was whether the Integra or allograft should be meshed (usually 1:1) or not. We tended not to mesh the allograft or Integra (64.7% not meshed and 35.3% meshed). Patients were followed up for need for any reconstructive surgery to the face during the same admission or at the first readmission after discharge.

5 580 Greenhalgh et al September/October 2013 Table 4. Characteristics of reconstructive surgery Proportion of Patients Average No. of Surgeries Reconstructive Procedure No. of Patients Reconstruction during first admission 24.5% (39 patients) 1.97 Eyelid release 36 Tarsorrhaphy 3 Lip release 9 Neck release 5 Cleft lip reconstruction 1 Nasolabial fold release 2 Forearm flap to forehead 1 Reconstruction during subsequent admission 57.1% (80 patients) Approximately, a quarter of the patients (39, 24.5%) had a reconstructive procedure during the initial hospitalization (Table 4). Most of the patients required eyelid contracture releases for ectropia (36, 22.5%) but patients also needed releases of lips (9, 5.6%), neck releases (5, 3.1%), tarsorrhaphies (3, 1.9%), and a few other procedures. One patient required a forearm flap to cover exposed bone. The patients had a mean of roughly two procedures during their first admission. Overall, there was 21.1% graft failure rate (requiring at least a partial regraft) and 16.7% were because of infection. We tried to determine whether there were any differences in complications between the different grafting types (Figure 1). One must remember that in this retrospective review, there was a tendency to use allograft when there were worries about the viability of the wound bed and so it was used in higher-risk patients. The risk of needing reconstruction was higher in the group receiving allograft, which, again was probably because of the depth of injury. It also appeared that there was a higher rate of graft loss with either Integra or allograft. Interestingly, we found a higher infection rate with Integra. When comparing a one-stage to a two-stage procedure, there were no differences in the numbers of complications or outcomes that could be noted (χ 2 = ; Figure 2). We have subsequently stopped excising on 1 day and grafting on the next day. We have provided examples of three patients who have had the U-shaped wrap-around graft. The patient in Figure 3 arrived soon after his burn with obvious full-thickness burns to his hands and face (Figure 3A). We thus had plenty of donor sites available to perform immediate autografting to his face and hands. The back had one U-shaped piece of skin harvested (with room for a piece in the middle of the back) (Figure 3B). The U-shaped skin was then wrapped around the face with a seam being placed at the lateral lip. The face graft at a year and then 10 years after the graft is quite acceptable. He had composite eyebrows grafted and some releases to the nasolabial folds (Figures 3C G). A second African- American boy had a similar wrap-around graft. He had Integra placed on his anterior trunk while we harvested donor skin from his back and thighs for immediate grafting to his hands and face. The lack of seams makes the face graft very socially acceptable Figure 1. The comparison of the outcomes of face burns treated with autograft, allograft, or Integra is provided in graphical form. It is clear that there is no advantage to one graft technique or the other.

6 Volume 34, Number 5 Greenhalgh et al % 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Comparison of Outcomes in 1 or 2 day Graft Procedure Graft Failures % of graft failures d/t infection Percent Reconstruction at any point 2 day surgery 1 day surgery Figure 2. The outcomes of face grafting were no different whether a one-stage or two-stage procedure was performed. (Figure 4). He has been doing very well out in public. The last patient had similar isolated face burns which were treated with the U-shaped grafts (Figure 5). The graft had a good appearance at 2 weeks after placement (Figure 5A C), and with time the result was quite good (Figure 5D F). DISCUSSION Face burns are a challenge for all burn surgeons. If the burn has or will not heal within 2 to 3 weeks then a permanent change in the face is inevitable. The challenge at that point is to perform the best treatment that is possible to minimize scarring. The use of basic principles for managing these burns will provide the best chances for a good outcome. One principle is to provide the best graft possible the first time to minimize complications. The concept of providing a thin or suboptimal graft with the goal of performing later reconstruction leads to more problems in the future. Attempts should be made to work for the best color match for smaller grafts so that there is no contrast between the pigment of the natural skin and graft. Scalp skin will allow for the best color match if it is available. Thicker skin contracts less so that the goal should be to harvest the thickest skin possible. Thicker skin does lead to the challenge of transferring hair (and leaving alopecia) when using the scalp. Scraping hair off does help this matter to an extent. There is also a significant debate as to whether an entire aesthetic unit should be excised and grafted when only part of it is burned. We find it difficult to remove an entire unit if only a small part is burned but will do so if most of the unit is injured. We feel that saving some of a unit for potential future tissue expansion is a good reason to leave some portion of a unit behind. In addition, if excision near more mobile regions of the face can be avoided then there are fewer chances of ectropia or other contractures. Parts of the face that are on firmer surfaces and in less mobile places, such as the forehead are very forgiving but those that are on or near mobile places such eyelids or lips tend to have less resistance to contracture. We, like others, feel that all seams should be placed at the junctures between aesthetic units. Any seam between skin grafts will have greater contracture than the central part of the graft. One option to minimize contractures of a seam is to break up the line by creating a dart or Z-like break in the seam. 15 The best way to minimize contractures at a graft juncture is to eliminate the seam. Therefore, we developed the wrap-around or U-shaped technique to minimize seams. This technique has led to excellent results (Figures 3 and 4). The only other article that described a technique of eliminating seams was from China where in a single-patient case report a large, full-thickness skin graft is placed on a patient. 16 Several other authors have described their techniques of managing face grafts. 6 9 Some, in the past, have suggested that face burns should be treated conservatively 3 5 but most current burn surgeons agree that delayed closure or late grafting leads to worse results. 1,6 10 More recent articles describe different but relatively similar methods of grafting the face. Several advocate two-stage procedures to minimize bleeding. 6 9 We used that technique for a while but found that there were no advantages to performing two-stage techniques. There were still areas of bleeding that needed to be controlled on the second day and there did not seem to be any reduction of hematomas. We also place allograft or Integra on the face in the first stage. Often these temporary covers were used because the available donor skin was used in other places. The idea that Integra or allograft had any advantage was not borne out in our study. We now feel that if skin is available that early, a one-stage approach of excision and autografting with the largest (U-shaped if possible) and thickest skin graft is the best choice.

7 582 Greenhalgh et al September/October 2013 Figure 3. We present a series of photographs of one of our patients who underwent a U-shaped wrap-around graft of the face. The patient presented with isolated face and hand burns (A). The U-shaped donor site is shown after healing. The graft was harvested starting at the right buttocks, extended up the right side of the back, around the upper back, down the left back, and finished at the left buttock. The graft was wrapped around the face, with the seam being placed at the edge of the right commissure (B, C). The back donor site is seen after 10 years (D). The patient had some Z-plasties and eyebrow composite grafts and he still has a good outcome after 10 years (E G). Another debate that has persisted in the burn world is whether these patients should receive tracheostomies or not. Many of our colleagues feel that tracheostomies are unnecessary and potentially may lead to greater airway complications. We have been performing tracheostomies in all of our major burn patients who are expected to need prolonged airway support. We place tracheostomies during

8 Volume 34, Number 5 Greenhalgh et al 583 Figure 4. The outcome of another child with a face graft is shown after 11 years. He also had composite eyebrow grafts. His outcome is excellent. the first burn excision, which is often postburn day 2. We have not seen any significant complications whether the tracheostomy is placed through burn or not. Clearly it is easier to perform the face graft without an endotracheal tube in place. Others have wired endotracheal tubes to teeth and have even placed arch bars. Certainly there are risks for those procedures. We reviewed our tracheostomy experience and found few complications and actually demonstrated improvements in airway mechanics. 17 The outcomes of the deep burns to the face have not been demonstrated in very many studies. In one of the largest series of 100 patients over 20 years, the Seattle group published pictures of all of their patients to reveal their late outcomes. 7 There was, however, no list of complications in this or the subsequent study from that region. 7,8 Clearly, the global Figure 5. The U-shaped graft for this girl looks quite good at 2 weeks (A C), and the ultimate result 8 years later is excellent (D F).

9 584 Greenhalgh et al September/October 2013 outcome of the face as seen by the community is very important and although we wish we could have shown all of our patients, the current Institutional Review Board do not allow pictures unless permission was granted by each patient. Philp et al 9, from Toronto, did focus on their outcomes in a very well-done study. They used actual measures of color match, return of sensation, extent of hypertrophic scarring using the Vancouver Scar Scale, and ectropion formation. Their results of 14 patients revealed findings similar to our study. They found that the color match was best with the scalp donor site and that areas of higher mobility (lips and eyelids) had more problems with contractures. Several of their patients required ectropion releases. Our review examined 160 face burns in patients with very large (mean of nearly 40% TBSA) burns. This study was a critical review of our outcomes, which revealed a significant number of patients who needed regrafting and early contracture releases. One could argue that our complication rate was quite high but one must remember that the most significant factor influencing the outcome of a skin graft is the severity of the original injury. In other words, patients with a simple third-degree burn who have large areas of available donor site have better outcomes. Unfortunately, our wide referral base includes patients from other countries who have sustained massive burns and have limited donor sites. Clearly, babies with deep face burns have special needs. Because of these factors, nearly a quarter of our patients needed an early contracture release, which most commonly involved the eyelids. These contractures seemed to occur whether or not we performed tarsorrhaphies. The prevention of ectropia has not been accomplished by any burn team. 9,16,18 In addition, many of our patients (57%) required at least some form of reconstruction. In the pediatric population, growth frequently increases the need for reconstruction because scars do not grow as fast as the underlying structures. Some of the reconstructive procedures were debatably cosmetic items such as creation of eyebrows, but we feel that any method to improve the ultimate outcome is worthwhile. In conclusion, treating face burns is a challenge but the challenge can be met with excellent results. Adherence to principles of early excision and grafting for any burn that will not heal in 2 weeks, and using aesthetic units is important. The technique of wrapping skin around the face reduces these junctional contractures. From our viewpoint, it is not necessary to perform a staged excision and grafting procedure because a one-time excision and autografting leads to excellent results. Problems still exist in the mobile portions of the face, especially at the eyelids or lips. Hopefully, improved techniques will deal better with these difficult areas. Overall, an aggressive approach to covering these difficult wounds leads to children whose outcomes allow them to lead happy social lives. ACKNOWLEDGMENTS Informed consent was received for publication of the figures in this article. REFERENCES 1. Kung TA, Gosain AK. Pediatric facial burns. J Craniofac Surg 2008;19: Deitch EA, Wheelahan TM, Rose MP, Clothier J, Cotter J. Hypertrophic burn scars: analysis of variables. J Trauma 1983;23: Bell JL. Treatment of acute thermal burns of the face. Am J Surg 1959;98: Boswick JA Jr. Burns of the head and neck. Surg Clin North Am 1973;53: McIndoe AH. Total reconstruction of the burned face. The Bradshaw Lecture Br J Plast Surg 1983;36: Housinger TA, Hills J, Warden GD. Management of pediatric facial burns. J Burn Care Rehabil 1994;15: Cole JK, Engrav LH, Heimbach DM, et al. Early excision and grafting of face and neck burns in patients over 20 years. Plast Reconstr Surg 2002;109: Friedstat JS, Klein MB. Acute management of facial burns. Clin Plast Surg 2009;36: Philp L, Umraw N, Cartotto R. Late outcomes after grafting of the severely burned face: a quality improvement initiative. J Burn Care Res 2012;33: Fraulin FO, Illmayer SJ, Tredget EE. Assessment of cosmetic and functional results of conservative versus surgical management of facial burns. J Burn Care Rehabil 1996;17: Gonzalez-Ulloa M. Restoration of the face covering by means of selected skin in regional aesthetic units. Br J Plast Surg 1956;9: Greenhalgh DG, Barthel PP, Warden GD: Comparison of Back versus Thigh Donor Sites in Pediatric Burn Patients. J Burn Care Rehabil 1993;14: Housinger TA, Lang D, Warden GD. A prospective study of blood loss with excisional therapy in pediatric burns. J Trauma 1993;34: Parry I, Palmieri T, Sen S, Greenhalgh D. Scar management of the face: does early versus late intervention impact outcome? J Burn Care Res. 2013;34: Greenhalgh DG, Palmieri TL. Zigzag seams for the prevention of scar bands after sheet split-thickness skin grafting. Surgery 2003;133: Zhao JH, Diao JS, Xia WS, Pan Y, Han Y. Clinical application of full-face, whole, full-thickness skin grafting: a case report. J Plast Reconstr Aesthet Surg 2012;65: Palmieri TL, Jackson W, Greenhalgh DG. Benefits of early tracheostomy in severely burned children. Crit Care Med 2002;30: Barrow RE, Jeschke MG, Herndon DN. Early release of third-degree eyelid burns prevents eye injury. Plast Reconstr Surg 2000;105:860 3.