Closure of Partial-Thickness Facial Burns With a Bioactive Skin Substitute in the Major Burn Population Decreases the Cost of Care and Improves Outcome

Robert H. Demling, MD, Leslie DeSanti, RN

Disclosures

Wounds. 2002;14(6) 

In This Article

Discussion

Partial-thickness burns to the face, especially in the presence of a major body burn, require considerable facial care to control pain, avoid exudate buildup and infection, and thereby decrease the potential for scar formation.[1,2,3,4] A temporary skin substitute can lead to immediate wound closure, decreasing pain and wound care, although this specific aspect has not been studied. The authors studied major burn patients with partial-thickness facial burns because of the ability to better assess outcome and care effectiveness of the facial burn itself.

The standard of face care in this population is the use of topical antibiotic creams or ointments, which are removed and reapplied twice a day to avoid infection and dessication. Topical antibiotic use has the potential advantages of the decreased cost of the antibiotic agents compared to a temporary biologic skin substitute. However, the data presented indicates that this decreased cost is more than neutralized by the increased costs of nursing time, pain medications, and other drugs needed to remove and replace these agents. This well-adhering temporary skin substitute rapidly closes the burn wound after which face care is minimized to only removing the plasma exudate that occur at the seams. The rolling out of any exudate buildup beneath the substitute is required mainly on day one and is usually not required by day three.

The disadvantage of using an open wound care technique on the face is the increased pain that occurs with removal and reapplication of the antibiotic agents. In addition, the majority of these agents impair wound healing including re-epithelialization. Also, an open wound causes a greater overall systemic "stress response" than a closed wound. Nearly half of our study population of facial burns also required endotracheal intubation due to concerns of a compromised upper airway from facial edema and smoke-inhalation-induced lung dysfunction. In this population, removal of wound exudate from a partial-thickness burn is time consuming and poses an increased risk because the patient may dislodge the endotracheal tube in response to the pain associated with this procedure. The use of the skin substitute not only diminishes the need for cleaning the face around the tube but also eliminates the startle reflex.

Increased narcotics and sedation were needed in the standard facial care group, both of which can lead to the secondary complications of respiratory depression, hemodynamic changes, and ileus. Immediate closure of a partial-thickness facial burn improves patient comfort and requires less narcotics. Use of the skin substitute also improves healing as local wound trauma, dessication, bacteria colonization, and exudate are decreased.[1,7,8,9]

The skin substitute used in this study is a bilayered, biologically active, temporary skin substitute. An outer flexible knitted nylon is impermeable to bacteria but permeable to water vapor, which decreases environmental insults. The inner layer contains bioactive skin fibroblast products, especially human fibronectin, which produces a rapid adherence to a cleaned partial-thickness wound bed.[1,2,3,4,5,10,11] The product is also very flexible and conformable. These properties produce an excellent adherence to the face where contour changes and movement require a rapid and tight adherence. Therefore, no daily wound trauma or colonization occurs, and a moisture layer is maintained between the inner adherent layer and the wound substitute surface, optimizing the healing environment.

In all cases in our study, the skin substitute remained adherent and without infection, providing an optimum healing environment while requiring minimal care.

The potential disadvantage of this temporary skin substitute is its use on a wound that has not been adequately debrided, which will impede adherence. Also, this agent is more difficult to use on a burn that has been treated open for 24 to 48 hours, because removing necrotic debris without general anesthesia is difficult. Therefore, early wound closure needs to be initiated in the early post-burn period to be effective.

The use of a bioactive adherent skin substitute for management of partial-thickness facial burns in the presence of a major burn improves patient comfort and healing rate and is cost effective.

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