Traumatic Facial Burn Injuries
Every year in the US, there are 1-2 million burn injuries seen by doctors and emergency rooms. Facial burns take up many of those burns. In facial burns, there are often many specialty doctors involved so that the patient can maintain airway patency, corneal protection, oral incontinence, and other aspects of facial comfort, appearance, and function. The idea is to minimize the deformity of the face by making the patient have a near-normal look again.
The skin is made of three primary layers, including the epidermis, the dermis, and a fatty layer beneath it. The purposes of skin are to perform thermoregulation, immunological protection, protect the area from trauma and UV radiation and to control insensible water loss. The epidermis is the outer layer that contains no blood vessels. It is dependent on nutrition entirely on the vascular dermis.What is Facial Burn Injury?
A facial burn injury can happen from a thermal burn, such as in a fire, or a chemical burn, such as with acid or lye. Each type of burn is treated slightly differently and has a different outcome. Burns, as a rule, involve the destruction of the cells of the skin and sometimes deeper structures like the fascia, muscle and bony tissues.Depth of Burns
Burns are identified by their depth or “degree”. A first-degree burn is the most superficial. The damage is confined to the area of the skin known as the epidermis. It can be a flash flame burn, a scalding injury or even a sunburn. The burn remains dry and has no blisters. There is usually no residual scar and healing occurs over 10 days or less.
A second-degree burn is also called a partial thickness burn. It burns the epidermis and a part of the dermis, leading to a painful area that blisters. It can be caused by flame, hot liquids or hot solids. Chemicals can cause a painful wound as well. The burn tends to be red and inflamed. Most spontaneously re-epithelialize from leftover epithelial cells in the skin and take about 10-14 days to heal. It does not need any grafting. Deeper partial wounds may take up to 30 days to heal and can get infected, turning it into a full-thickness injury.
Third-degree burns or “full-thickness burns” wreck the epidermis, the whole dermis, and sometimes the deeper layers of tissue. They do not hurt because of the loss of the nerve endings in the burned tissue. They can occur because of an association with hot liquids, flame, hot solids, electricity or chemicals. It is a dry, leathery burn that is gray, white, green or translucent. It eventually turns brown or black. With facial burns of this depth, surgical intervention is required to replace lost skin through a skin graft.Causes of Facial Burns
Facial burns are always traumatic but they can be caused by many different things:
- The face can come in contact with a hot surface like a stovetop or occupational surface, usually causing first or second-degree burns.
- The face can connect with a corrosive substance, such as an acid or lye. Acids tend to be less serious burns because they cauterize the tissue and don’t go deeply into the skin, while caustic lye burns can go deeply into the tissue and cause deep third-degree burns.
- Friction can cause heat to form within the skin tissue and can cause a dry first-degree burn that usually hurts but heals quickly
- Wet heat like hot liquids or steam can burn the face, leaving behind a first or second-degree burn
- Extreme cold can cause a frostbite burn to the face. In extreme cases, this can be a full-thickness burn that destroys a great deal of tissue.
- Radiation can cause deep burns and can be from the sun’s UV rays or from radiation because of a nuclear blast as in Hiroshima or the Chernobyl accident.
- Certainly, fire can cause a first, second or third-degree burn. Fires can come from burning homes, burning recreational pits or grills, and motor vehicle accidents.
- Burns from electricity are often difficult to inspect because the burn can go very deep but can be only partially visible from the outside. Electrical burns to the face should be taken very seriously.
Burns are measured by the “rule of nines”, which tells the doctor what percentage of the body is injured. This measurement is just as important as the depth of the wound. The rule of nines is adjusted somewhat for babies and small children who have different proportions than adults. The calculation is based on the amount of body part that is about 9 percent of the total body area of one hundred percent.
The rule of nines is this:
- Head—9 percent
- Chest—9 percent
- Abdomen (front only)—9 percent
- All of back and buttocks—18 percent
- Each arm—9 percent
- Each Palm—1 percent
- Groin—1 percent
- Each leg, front—9 percent, and back—9 percent
When checking the area of burning involved, only the second and third-degree burns are totaled. First-degree burns tend to hold onto water so, unlike second and third-degree burns, there aren’t the fluid losses involved.
If the burn involves more than 15 percent to 20 percent of the body area, there can be significant fluid losses and the presence of shock. IV fluids are indicated whenever there are large areas of 2nd and 3rd-degree burns involved. According to the Parkland Formula for traumatic burn fluid loss: 4 cc of fluid per kilogram per percent of burn is equivalent to the fluid given in the first twenty-four hours, with the first half given over 8 hours. This involves about 8000 cc of fluid in a 175-pound person with a 25 percent burn.
The greater the percent of skin burned, the greater is the risk of death. Those with burns less than 20 percent of their body area involved will generally survive but those with burns covering greater than 50 percent of the body have a much higher mortality risk, depending on age and the presence of other medical conditions.Signs and Symptoms of Facial Burns
The signs and symptoms of a burn depend on the type of burn. For example, a superficial first-degree burn will be dry and red. It will be perceived as fairly painful. The skin is red but will blanch and turn white when one presses on it. There may be some swelling of the skin. There are no blisters and no insensible fluid loss. This is a burn that looks a great deal like sunburn. It tends to fade over a 5 day period of time.
A superficial, partial thickness, a second-degree burn is moist with a weeping red base. The epidermis can separate from the dermis, causing a fluid-filled blistery wound. The area blanches from red to white when you push on it and the sensation of air on the wound leads to increased pain. It should be kept cool because heat makes the pain worse. It is one of the more painful types of burns because the nerve endings are raw and not burned up as in a third-degree burn.
In a deeper partial-thickness burn (a deep second-degree burn), the blisters are generally quite loose and easily removed. The remaining skin might be moist or a waxy dry. The skin color is a patchy blend of red to white and the skin doesn’t blanch regardless of the amount of pressure put on it. It may or may not be painful, depending on the amount of nerve damage; however, the patient may feel pressure when touched.
In a full-thickness burn, the skin looks gray, like leather, white and waxy or charred and blackened, depending on the type of burn. If any of the nerve endings are damaged, the only sensation the patient feels is that of deep pressure on palpation.Treatment of Facial Burns
It’s important to quickly look at cause when treating a facial burn. Fast treatment is vital in lessening tissue destruction. You need first to think of first aid for facial burns.
- Putting a cool, damp cloth on the burn to cool the skin. Don’t use ice as this can damage the tissues.
- Don’t use ointments, butter, oils, or grease on the burned area.
- Cover the burn with a dry piece of clean cloth or a sterile gauze.
- Don’t cover the burn with a fluffy towel or blanket.
- Take Tylenol for the pain.
- Don’t pop or break any blisters because they can get infected.
- See a doctor with any signs of infection, including increased pain, redness, oozing of pus, swelling or fever.
When a burn has been completely cooled, use a fragrance free lotion or moisturizer to prevent drying, if the wound is very minor. If the wound is more serious, such as a partial thickness or full thickness wound, call 911 or seek medical attention.
Until you seek medical attention for severe burns, don’t remove clothing stuck into the burn. Don’t expose the burn to further heat and smoke. Don’t soak the burn in water but instead cover it with a sterile gauze that is moist or a clean, moist cloth. If the burn is part of a severe injury, make sure that the person has an intact airway and that you have started CPR if this is proven necessary. If the wound is more than minor, seek medical attention immediately.Do I Need to Be in the Hospital?
Sometimes the decision is made to put the patient in the hospital. There are several reasons a doctor might decide to hospitalize a patient with a severe burn. In part, it depends on the depth and extent of the burn. The other factors include:
- Age less than five years or greater than 55 years of age.
- Suspected child abuse
- Deep burns on the hands, eyes, face, feet, or perineum
- An extensive burn on the rest of the body
- Burns that require complex dressings, elevation or observation
- Electrical burn
- Problems with an inhalation injury
- Circumferential burn
- Other medical problems like diabetes, sickle cell anemia, medical treatment, and immunosuppression
Very bad thermal and flame burns need oxygen to improve breathing, intravenous fluids to replace fluids lost through the burn, splints on the joints to help maintain mobility, and sometimes physical therapy.
Skin grafting is important for deep partial thickness or full thickness burns. It involves scraping a lattice of skin off of an unburned area. The latticed-area stretches nicely to cover the burned area. Then the lattice is then stapled to the burn. It promotes faster healing because it is already partially covered by the patient’s own skin. In some cases, cadaver skin needs to be used to temporarily cover the burned area but it doesn’t last; it is just a temporary measure to protect the burned tissue so it can eventually heal itself.Complications of Facial Burns
Facial burns can be fraught with complications if not treated carefully. The biggest complication of facial burns is scar tissue. Depending on how the wound heals, there can be no facial scarring or deep ridges and scars within the skin. It can cause a deformed mouth, nose or eyes as a result of poor healing.
Infection is also possible. A bacterial infection of the burn can remain at the sight of the burn and can cause poor healing and scarring. It can also spread through the burned skin to infect the bloodstream. When this happens, it becomes septicemia or sepsis, which is very dangerous and life threatening. It can result in organ failure, shock, and death.
If a burn is big or moist enough, it can leak fluid from the body and can cause hypovolemia. Serious hypovolemia turns to shock and this is a symptom that can be life threatening if not treated aggressively.
A facial burn especially can lead to breathing problems from smoke inhalation. In the early stages of a burn, the doctor doesn’t know how much smoke the patient has inhaled so he must err on the side of caution and use oxygen or intubation if it appears the patient is low on oxygen.
Hypothermia can happen if the patient loses too much heat through the damaged skin. This is a bigger problem if the wound is large but can happen on full thickness facial burns. The body cannot maintain its temperature if too much skin is lost.
Joint problems around the jaw can happen with facial burns, especially if the patient doesn’t exercise his or her mouth after the burn. The patient needs to do physical therapy to keep the jaw muscles and joint moving at all times.
A serious burn is a catastrophe. Anyone who has a serious burn thru the negligence of another should contact an experienced catastrophic injury lawyer.
The following video provides an understanding of a burn injury. It discusses the different types of burns and how they are treated.Sacramento Burn Injury Lawyer
I’m Ed Smith, a Sacramento Burn Injury Lawyer. If you or a loved one has suffered a facial burn injury as a result of someone else's negligence and would like to discuss your legal options with an experienced Sacramento Personal Injury Attorney, contact us online or call us at 916.921.6400 or 800.404.544 for free, friendly advice.
Photo by Ihor Malytskyi on Unsplash
Editor’s Note: This page has been updated for accuracy and relevancy [cha 11.25.19]