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Greenhalgh. Plast Aesthet Res 2024;11:27 https://dx.doi.org/10.20517/2347-9264.2024.43 Page 11 of 13

Figure 12. A patient with 31% third-degree burns to his entire head, face, arms, hands, and legs nearly 10 years ago. He underwent sheet
grafts on his hands [Figure 5] and face, with meshed grafts in the other areas. He had a “wrap-around” face graft (A, B, and C), with
some areas of loss to the right side of the face (B). He had a recent right neck contracture release with a graft under the angle of the jaw
(B). The “wrap-around” face graft leads to an acceptable outcome despite requiring separate grafts to most of the scalp. The seam is
seen coursing inferiorly from the right commissure when looking straight at (A). There are no seams on his left side (C). The patient
provided consent for the use of the picture.

eyelid contractures, but mouth/commissure contractures also occur. We use hard and soft facemasks, along
with silicone patches, to help with hypertrophic scarring. Creating traction to counteract graft shrinkage by
taping areas such as the eyelids also helps. Again, prolonged, aggressive therapy and scar management are
essential to optimize the outcomes of face burns.

Optimizing outcomes of large burns
The functional and cosmetic outcomes of burns are dependent on several factors. Clearly, very deep burns,
especially fourth-degree burns, are more difficult to deal with. Small areas of exposed bone or tendon can
often be covered with dermal substitutes, and when vascularized, they can be grafted. Areas of exposed skull
can have the outer table burred to allow for granulation tissue growth and eventual grafting. Various flaps
can also be used, but this paper will not cover flaps. Obviously, patients with massive burns will not have
enough donor skin to use sheet grafts, so compromises must be made. The strategy of promptly removing
visibly deep burns (within a few days) is important, as it helps suppress the hypermetabolic response .
[23]
Some of the strategies described earlier can still be used to improve outcomes in more functional or
cosmetic areas. For instance, we often use sheet grafts for the hands and faces of patients with burns > 80%
TBSA. The rest of the areas are covered with widely (4:1) meshed grafts. One of the problems we had in the
past was the delay in re-epithelialization of the interstices of wide mesh. We have found that spraying
autologous epidermal cells (RECELL®, Avita Medical, Valencia, CA) fills the interstices rapidly, and appears
to accelerate the healing of the donor sites. (A more expansive description of RECELL® will be covered in
another paper in this review.)

When all of the donor skin has been utilized, the remaining excised burn should be covered with a
temporary “skin”. We have found that allograft does not work as well as in the past. Allograft tends to
degrade after 2-3 weeks, leaving granulation tissue. A better option is to cover the wound with a dermal
substitute. While we have used Integra® (Integra Life Sciences, Princeton, NJ) in the past, we currently use
NovoSorb® BTM (PolyNovo North America LLC, Carlsbad, CA), which is a polyurethane foam covered
with a polyurethane surface as a temporary covering. The product takes around two weeks to vascularize,
but it can also develop a prolonged, quiescent state that protects the underlying tissue without signs of
inflammation. As an example, it persisted without infection on the face for a patient with 90% TBSA burns