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Paper text:
asian faces tend to scar badly after burn injury and despite the best of efforts , results are not satisfactory . compared with caucasian patients ,
asian burn wounds tend to scar much worse because of increased skin thickness and sebaceous gland activity .
chemical burns to the head and neck are recognised to be a particularly challenging category of burns .
we managed to obtain a good result in a case of acid burns of the face and we highlight the techniques used to overcome the challenges of managing the asian burnt face .
a single thorough wound debridement was performed involving sharp excision of burned skin down to dermis and fat [ figure 1 ] . at the orbicularis occuli , we excised down to muscle .
skin cover was planned as follows : the best skin was harvested for the most critical areas and injured areas were prioritised ( in decreasing order of importance ) as the eyelids , the nose , the cheeks , the preauricular area and the forehead . for the eyelids , full thickness skin from the supraclavicular area was harvested . for the nose and cheek ,
this increased the surface area and allowed us to use the 4  air dermatome to obtain large sheet grafts .
hair that was stuck to the scalp grafts was removed to prevent it from acting as a foreign body .
the donor scalp defect was secondarily grafted with meshed skin grafts to allow subsequent hair growth . for the forehead and preauricular area , skin from the thigh
postdebridement - showing healthy granulation tissue prior to grafting skin placement following the principles of aesthetic units . for the nose and cheek ,
, thigh skin was used . note that fenestrations were made along the relaxed tension lines
before the grafts were applied , slow acting fibrin glue was sprayed giving us a short while to make minor adjustments to the graft position before the glue sets .
silk 6/0 sutures were used to stitch the graft at the junction lines of the aesthetic units .
the junction lines of the aesthetic units were precisely matched to minimise scarring and sutures bites were taken deeper to ensure that grafts were not resting on suture material .
after securing the graft , fenestrations were made in the graft to drain any collection [ figure 2 ] .
commonly , this is done before skin is laid on the wound bed but we made them after the skin was laid down to ensure that they did not violate tension lines .
take , stitches were removed on the eighth postoperative day and the patient was discharged . at our patient 's first year visit , he had a missing right eyebrow and half his anterior scalp was absent [ figure 3 ] .
two tissue expanders were inserted ( 500 and 700 ml ) to restore hair - bearing scalp to the temporal and parietal areas [ figure 4 ] .
the tissue expanders were inserted through remote incisions to reduce the risk of wound dehiscence and scar stretch during expansion .
the patient was advised to sleep upright and to avoid pressure on the expanders . at the time of expander
removal and scalp flap inset , the galea was scored to allow us to cover the required area .
appearance after 1st stage reconstruction showing missing right eyebrow and absence of anterior half of scalp insertion of tissue expanders .
the black line marks the hairline and the red line marks the superficial temporal artery our next stage involved hair transplantation to recreate the right eyebrow . a single - strip autograft was obtained from the inferior border of the hairline at the nape of his neck [ figure 5 ] taking care to match the orientation of the hair follicles by comparing with the unaffected eyebrow .
showing the absent eyebrow , harvesting from the nape of the neck , placement of the graft and the final reconstructed brow the right alar base was scarred down leading to obliteration of the alar - facial groove .
a composite antihelical chondrocutaneous graft was harvested from the right ear to reconstruct the groove .
( a - e ) reconstruction of the right alar - facial groove . ( a ) harvesting of composite antihelical chondrocutaneous graft ; ( b ) graft used to cover alar facial groove ; ( c ) conchal transposition flap used to cover donor site .
arrow shows direction of movement of flap ; ( d ) after covering donor site with chondrocutaneous flap , a resultant secondary defect exists ( marked with an asterix ) ; ( e ) secondary defect skin grafted .
( f ) the reconstructed alar - facial groove ; and ( g ) the donor ear
despite the advances in burns management , we find that asian skin is particularly prone to scarring and the cosmetic result is not satisfactory .
the ratio of keloid or hypertrophic scarring in non - whites compared to whites has been quoted to vary from 5:1 to 15:1.[35 ] orientals have thicker , more seborrhoeic skin than caucasians accounting for the higher incidence of keloid formation .
these include different anatomical regions , races , wound depths , injury types , genetic factors , prolonged immunological responses , infection and skin tension .
these mediators in turn cause abnormal fibroblasts responses which can result in hypertrophic or keloid scarring .
grafting was not performed immediately after debridement to allow for the growth of healthy granulation tissue and to monitor for bleeding .
the timing for grafting is critical - delayed skin grafting leads to excessive granulation tissue resulting in scarring . on the other hand ,
it is important , therefore , to obtain a balance in granulation tissue . in our case
, we waited 5 days when there was healthy granulation tissue and no oozing or bleeding .
firstly , the proper matching of aesthetic junction lines and the avoidance of graft overlap minimises scarring .
any scars that do form will be along junction lines and blend in with natural skin creases of aesthetic units .
fenestrations were made after the skin was laid down so that they follow the curvature of the underlying muscle .
for instance , near the eye , the pattern of our fenestrations mimicked the circular shape of the orbicularis oculi muscle .
it is important to free up all scar tissue and in our patient , the orbicularis occuli was stuck down and had to be completely freed .
inadequate freeing of the orbicularis occuli would have led to insufficient grafting and shortening of eyelids manifesting as lid retraction and ectropion .
movement of eyes during blinking and oral movement during mastication may lead to poor graft take .
a frost tarsorraphy was used for 5 days to prevent eyelid movement and a nasogastric tube was inserted to prevent chewing movements .
the frost tarsorraphy also kept the eyelid skin stretched and prevented the graft from contracting .
our patient was advised not to talk or actively move his mouth for 1 week .
the difficulty in immobilising the cheek and lips has been noted by other authors and they immediately applied splints and pressure dressings . at the initial stages
, we relied on our quilting sutures as a substitute for pressure dressing to aid in graft adherence to the wound bed .
we feel that the application and removal of pressure devices may put unnecessary shearing forces on the delicate skin grafts and mask detection of any underlying hematoma .
although skin grafting formed the mainstay of our skin reconstruction , integra has been used as an alternative to grafting .
we find that this process takes a long time and is best used for patients with shortage of native skin .
postburn scalp alopecia has been classified according to the extent and density of hair loss .
our patient would be classified as a type 1a with a single alopecic segment and less than 25% of hair bearing scalp lost . to reconstruct this alopecic patch ,
we recommend starting tissue expansion at least 6 months after all wounds have healed . by 6 months
, the full extent of scarring can be assessed and a suitably sized expander can be used . in our case , we used two expanders to cover the alopecic patch with satisfactory results . in some instances ,
tissue expansion has also been used to replace facial skin as the thinner expanded skin can provide a  near perfect  match to facial skin .
our maintenance therapy included pressure garments at one month and silicone sheeting to prevent hypertrophic scarring .
our patient was very compliant with treatment and persevered with pressure garments despite local heat and humidity .
postoperative photos taken after 5 years our next aim was to reconstruct the right eyebrow and the right alar base .
the superficial temporal artery flap has been described before but there are problems with the extensive dissection and donor site alopecia .
a more recently described option is the subcutaneous pedicle island flap which carries the risk of injuring the frontal branch of the facial nerve .
we did not perform either flap as the donor scalp was burnt . with regards to the nose , retraction of the alar margin is common and requires replacement of both cover and lining .
the asian patient 's thick skin predisposes him to hypertrophic and keloid scar formation . with our technical factors ,
this article describes the management of chemical burns to the asian face with resultant full thickness loss to the right side of the face including the eyelid and nose . 
 we detail the techniques used to reconstruct the face which include skin grafting according to the aesthetic units of the face , accurate placement of junction lines , use of a chondrocutaneous graft to reconstruct the alar grove and scalp strip grafting for eyebrow reconstruction . 
 we obtained a successful result that minimised scar formation in the burnt asian face .