Application of minimally invasive debridement for deep second-degree facial burns in the early postburn phase

Abstract

Objective

This study aimed to evaluate the therapeutic efficacy of minimally invasive dermabrasion for deep second-degree facial burn wounds during the early postburn phase.

Methods

A total of 35 patients with deep second-degree facial burns underwent minimally invasive debridement using a hydrosurgery system within 2–4 days post-injury. Subsequently, the wounds were covered with human biological dressings. The wound infection rate, healing time, and overall healing quality following debridement were monitored.

Result

In this cohort of 35 patients, no infections were reported after debridement. The average healing time for these wounds was significantly shorter than that of those treated with standard surgical excision. Clinical observations indicated that minimally invasive dermabrasion was associated with a lower infection rate and reduced healing time. After 6 months, scar assessment using the Vancouver Scar Scale showed that the average score for wounds treated with minimally invasive techniques was lower than those treated with standard surgical excisional technique.

Conclusions

This research indicates that minimally invasive debridement during the early postburn stage can effectively reduce wound infection rates, shorten healing times, and minimize the occurrence of scar hyperplasia and contracture deformities. Therefore, minimally invasive dermabrasion is valuable in treating deep second-degree facial burn wounds.

Introduction

Burn injuries pose a significant public health challenge globally, with deep second-degree burns representing a considerable proportion of these cases [1]. Common causes include thermal, chemical, and electrical sources [2]. According to the World Health Organization (WHO), burns affect millions of individuals annually, leading to substantial morbidity and mortality [3]. The face, being an exposed body part, is particularly susceptible to burns, with deep second-degree facial burns occurring frequently due to inadequate protection. Facial burns are managed conservatively through exposure or semi-exposure therapy. Superficial wounds typically heal beneath a scab, while deeper wounds require scab dissolution or removal before autologous skin grafting. Despite the relative simplicity of these procedures, the surrounding tissue can become necrotic within a few days post-injury, and complications such as infections may arise, deepening the wounds and resulting in significant scarring that adversely impacts both appearance and function, ultimately affecting patients’ quality of life [4, 5]. As society progresses and medical advancements evolve, patients with deep facial burns increasingly expect effective treatment outcomes [6, 7]. Therefore, addressing deep second-degree facial burn wounds necessitates satisfactory wound healing and focuses on restoring appearance and function.

The hydrodynamic debridement system employs a high-pressure water stream for wound cleaning and debridement. This method relies on the kinetic properties of liquid flow, where water is delivered at high pressure through a jetting system onto the wound. This approach creates a powerful stream that removes necrotic tissue, foreign materials, and bacteria. Compared to traditional surgical excisional techniques, this approach minimizes trauma and promotes blood circulation through the mechanical action of water flow, promoting wound healing. Furthermore, the hydrodynamic system allows temperature and pressure adjustment to accommodate various trauma types and depths, ensuring adequate debridement while minimizing damage to surrounding healthy tissue [8]. This study aimed to assess the effectiveness of minimally invasive dermabrasion surgery compared to standard surgical excisional techniques to determine the most effective treatment option. The details of the report are as follows.

Methods

This study was approved by the Ethics Committee of the Affiliated Hospital of Nantong University (ethical approval number: 2019-K059). Informed consent was obtained from all participants.

Clinical data

A total of 35 patients with deep second-degree facial burns were included in this study, comprising 26 men and nine women. The patients’ ages ranged from 1 to 55 years, with a mean age of 25.22 ± 14.33 years. The burn types included 21 cases of fire burns, five of electric arc burns, four of boiling water burns, and two of steam burns. The remaining three cases involved boiling oil, chemical, and molten aluminum burns. The total wound area varied from 1 to 75%, while facial wound areas ranged from 1 to 3%. A Versajet II hydrosurgery system (Smith & Nephew, Inc., England, London, UK) was utilized for minimally invasive dermabrasion. The biological dressings were supplied by Shanghai Ren Kang Technology Co., Ltd. (Shanghai, China).

Another group of 70 patients with deep second-degree facial burns underwent standard surgical excisional techniques, comprising 14 men and 56 women. Their ages ranged from 1 to 71 years, with a mean age of 34.26 ± 18.7 years. This group included 39 cases of fire burns, five flash burns, 11 boiling water burns, and 12 chemical burns, with the remaining three involving boiling oil and incense ashes burns. The total wound area in this group ranged from 0.5 to 11%, while the facial wound area ranged from 0.5 to 3% [9].

Therapeutic methods

Preoperative preparation

Upon admission, all patients received symptomatic care, including debridement, dressing changes, fluid replacement, and antibiotics. In cases of dyspnea due to severe inhalation injuries, tracheotomies were performed as necessary. Facial wounds were covered with povidone-iodine gauze.

Operation method

Surgical procedures were performed under general anesthesia 2–4 days post-injury. The facial skin was cleaned with 1% povidone-iodine and draped for operation. A total of 35 patients underwent minimally invasive dermabrasion following this protocol: the water jet offers 1–10 power levels; typically, levels 2–4 are employed using the Versajet handle during operations. A gentle abrasion at levels 3–4 is recommended for flat areas, such as the cheeks. In contrast, delicate regions such as eyelids and lips require conservative grinding depth, typically using levels 2–3. If substantial necrotic tissue is present in deep second-degree wounds, level 4 can be utilized with the power level adjusted downward as necrotic tissue decreases. Moreover, the direction of the water jet should be modified based on the skin’s unevenness, such as around the nose, with power decreased accordingly. Furthermore, the water jet should be moved tangentially across the wound surface to avoid prolonged contact, possibly resulting in cutting injuries. In the remaining 70 cases treated with the standard surgical excisional technique, a Humby knife was employed to scrape the scab and remove as much necrotic tissue as possible while preserving viable dermis. Both methods eliminate non-viable tissue at the wound’s base until a bright porcelain white appearance or diffuse pinpoint bleeding is achieved. Local compression was frequently applied to control bleeding; if necessary, a saline and adrenaline solution (1:150,000) was utilized without significantly affecting systemic circulation.

After cleaning the wound with chlorhexidine, it was covered with a “human biological dressing,” which was sutured and secured in concealed areas, such as the hairline, behind the ear, and along the lower jaw. A sterile dressing was applied correctly. For the rigor of this research, all procedures were conducted by the same chief surgeon within the same treatment group. The “human biological dressing” was sourced from Shanghai Ren Kang Technology Co., Ltd., which received registration approval from the China Food and Drug Administration (National Medical Device Registration Approval 20153140015). This innovative burn wound covering was developed by integrating advanced technologies and processing techniques from the European Skin Bank headquarters with the skin characteristics of the Asian population. The product is taken from the epidermis and dermis of the human body. After special processing, it is sealed and stored in a sterile container with glycerol as the primary ingredient of a unique preservation solution.

Postoperative care

Postoperative care included standard anti-infective, supportive, and symptomatic treatments. Maintaining a clean surgical area was critical. If the outer dressing was contaminated by feeding or excessive exudate, it was promptly replaced. In cases of hematoma beneath the biological dressing, immediate drainage was performed.

Infection was monitored through signs of redness, swelling, pain, and discharge of purulent exudate, along with systemic indicators such as body temperature and heart rate. Bacterial cultures of the wound and blood were conducted. No wound infections were detected in any cases.

If no complications arose, dressings were changed 7 days postoperatively. Biological dressings were removed and replaced with Vaseline gauze and standard sterile dressings. Once wounds healed, silicone cream and a custom-fitted elastic mask were applied to prevent scarring. Scars were evaluated six months later.

Outcome variables

Post-debridement outcomes included wound infection rate, wound healing rate, healing time, healing quality, and scar formation. Scar severity was evaluated six months after healing using the Vancouver Scar Scale (VSS) (Table 1) [10]. The VSS evaluated the scars based on pigmentation, height, vascularity, and pliability, with higher scores reflecting more severe scarring.

Table 1 The vancouver scar scale

Statistical analysis

Statistical analyses were performed using GraphPad Prism 8.0. Unpaired t tests were used to compare minimally invasive dermabrasion surgery versus standard surgical excisional technique (Table 2). Values of p < 0.05 were considered significant.

Table 2 Comparison of minimally invasive dermabrasion and standard surgical excisional techniques

Results

No infections occurred post-debridement among the 35 patients with deep second-degree facial burns (Table 3). All wounds healed, with a 100% healing rate and a healing time of 9–17 days. The average healing time was 12.26 ± 2.15 days, with satisfactory healing quality. At a 6-month follow-up, 13 patients (37.1%) exhibited smooth, normal-colored skin, 16 patients (45.7%) had mild pigmentation, and six (17.1%) displayed minor, superficial scarring. No hypertrophic scars were observed. The VSS assessed the healing, yielding an average score of 0.86 ± 0.84. Two representative cases are detailed below.

Table 3 Information of patients treated with minimally invasive dermabrasion surgery debridement system (2016–2018)

Case one

A 21-year-old man presented with burns to the head, face, neck, and hands from an electrical arc exposure lasting over two hours. Examination revealed deep second-degree burns on the head, neck, and upper limbs, with the burn bases displaying red and white areas. Third-degree burns, characterized by pale wound bases, were present on both hands and wrists. The total affected area was approximately 7% of the Total Body Surface Area (TBSA) with an adequate peripheral blood supply. The diagnosis was “arc burns with second- and third-degree burns, 7% TBSA.”

Three days post-injury, precise dermabrasion of the deep second-degree burns on the face and neck was performed under general anesthesia using the hydrodynamic debridement system. After debridement, human biological dressings were applied (Figs. 1 and 2). Third-degree burns were excluded from this discussion. Biological dressings were removed seven days postoperatively, revealing partial wound healing and fresh wound bases with mild bleeding (Fig. 3). Regular dressing changes continued, and by 11 postoperative days, the wound was well-healed and covered by new pink epithelium (Fig. 4). Fifteen days postoperatively, the new epithelium had matured (Fig. 5). Three months later, the skin color of the face and neck appeared pinkish (Fig. 6), and at six months, the facial wound was smooth with a color similar to normal skin (Fig. 7).

Fig. 1

Preoperative image showing a red and white wound base

Fig. 2

(A-B) During the operation: post-debridement with the hydrodynamic system, dense hemorrhagic points appeared on the wound surface. (C) The wound was covered with an allograft

Fig. 3

After seven postoperative days, partial wound healing was observed after allograft removal

Fig. 4

After 11 postoperative days, the wound was fully healed

Fig. 5

The 15th postoperative day

Fig. 6

The third postoperative month

Fig. 7

The sixth postoperative month

Case two

A 36-year-old man presented with multiple injuries sustained 2.5 h prior from a liquefied gas explosion. Examination showed burns on the hair, eyebrows, eyelashes, and nose, with scattered injuries to the head, face, neck, limbs, trunk, and buttocks. Some wound bases were red and white, with others appearing slightly white. The total burn area was approximately 30% TBSA. The initial diagnosis included liquefied gas explosion burns (second-to-third degree) covering 75% TBSA, inhalation injury, and hypovolemic shock.

Following stabilization post-shock (Fig. 8), the patient underwent minimally invasive dermabrasion under general anesthesia on the facial deep second-degree burns. The wounds were then covered with a human biological dressing (Figs. 9 and 10). On the third postoperative day, the dressing remained intact with slight fluid accumulation beneath. After reinforcing dressing changes, the biological dressing was removed on the ninth postoperative day. Following iodine disinfection, the wound was covered with Vaseline gauze, nano-silver dressing, and sterile wrapping, changed every 2–3 days. The wound had essentially healed by day 16 (Fig. 11) (this case only shows the treatment of facial deep second-degree burn wounds). After six months, the facial wound had healed, with color closely matching normal skin (Fig. 12).

Fig. 8

Preoperative view showing deep second-degree burn on the face

Fig. 9

Facial wound appearance post-debridement with hydrosurgery system

Fig. 10

Biological dressing applied post-debridement

Fig. 11

Facial wound on 16th postoperative day, showing healing progression

Fig. 12

Six-month postoperative view, showing skin recovery

Discussion

Deep second-degree burns affect the dermal papillary and intermediate layers, leaving only the reticular dermis intact. Healing process is contingent upon deep dermal recovery and the regeneration of residual hair follicles, sebaceous glands, and sweat glands. It is well-known that facial topography presents challenges for bandaging. However, owing to the rich vascularity of facial skin, which is densely populated with sweat and sebaceous glands, there is significant potential for wound repair. The high activity of glandular cells, coupled with the robust vitality and rapid regeneration of basal hair cells, faciliates this healing process [11,12,13,14]. Consequently, traditional treatment for facial burn wounds involves exposed or semi-exposed conservative methods.

Recent clinical studies indicate that deep second-degree wounds frequently deepen in the early stages, leading to more pronounced scarring after conservative treatment. The key underlying factors include: (1) Early burn stages involve a microcirculatory, hypercoagulable state, resulting in static dermal microcirculation in the parabiotic tissue that, if untreated, transforms into necrotic tissue, deepening the wound; (2) Increased capillary permeability leads to tissue edema, ischemia, and hypoxia; (3) Persisting necrotic tissue elevates interleukin-8 (IL-8) levels, drawing inflammatory cells to the wound and hindering the release of growth factors essential for healing. Given these factors, conservative treatment may impede effective wound repair. Since 2002, our department has adopted an early surgical excisional technique for deep second-degree facial burns, leveraging the facial skin’s high regenerative potential [15]. In contrast to conservative treatment, this method enables the removal of necrotic tissue, reduces toxin absorption, and helps control infection. Consequently, the tissue microenvironment improves, allowing parabiotic tissue to regain its structure and function. Converting necrotic burn areas into incised wounds alters the healing trajectory and mitigates the risk of progressive wound deepening.

In clinical practice, deep second-degree burn wounds typically have uneven bases and irregular edges, especially on areas such as the head, neck, fingers, toes, and perineum. The distinction between normal and necrotic tissue is unclear, posing challenges for traditional debridement methods that typically use tools such as scalpels or Humby knives for direct tissue removal. These practical methods make achieving precise, minimally invasive debridement difficult and frequently cause varying degrees of trauma and bleeding, leaving residual necrotic tissue susceptible to infection. This sequela can prolong recovery, increase the risk of facial scar formation, contractures, and deformities, and cause significant patient discomfort. In complex cases, standard surgical excisional techniques may not yield optimal outcomes. Minimally invasive dermabrasion offers substantial advantages in treating deep second-degree burn wounds and has become increasingly adopted in clinical practice worldwide. Hydrodynamic debridement, used for over a decade in wound repair, has shown strong efficacy, leading to widespread acceptance [16,17,18,19,20]. This technique directs a high-pressure water jet through a small nozzle, creating a scalpel-like cutting effect [21] that generates localized negative pressure on the wound surface, efficiently removing necrotic tissue, bacteria, and inflammatory mediators. This approach maximizes the preservation of normal tissues and enables accurate, flexible, and minimally invasive debridement, enhancing wound healing outcomes [22, 23]. Compared to traditional excision, the hydrodynamic debridement system offers several critical advantages for deep second-degree facial burns [24]: (1) Its hydrodynamic cutting force avoids thermal damage to surrounding tissue structures; (2) It is user-friendly and requires minimal technical skill, facilitating broader clinical adoption; (3) Combining tissue removal with wound lavage in a controlled, layered approach provides precise debridement through a narrow, clear working field; (4) It allows for a debridement thickness of 50–100 μm [19, 25], compared to the 700–1700 μm thickness typical of traditional methods [26, 27]. Therefore, the hydrodynamic debridement system can minimize damage to the normal tissues and structures on the wound surface. It enables precise control over debridement depth and allows the operator to manage wound edges accurately, avoiding the “cliff-type” effect frequently seen with traditional debridement methods; (5) This system is particularly suited for hard-to-reach, uneven areas, such as the head, face, neck, fingers, toes, and perineum, challenging for conventional tools such as scalpel and Humby knives; (6) Furthermore, the system’s high tissue selectivity optimizes the wound bed, creating favorable conditions for healing. Overall, minimally invasive debridement better preserves healthy surrounding tissues, reduces bleeding risk, minimizes postoperative complications, and shortens recovery time [28, 29]. For complex conditions, including chronic wounds, diabetic foot ulcers, and other refractory diseases, minimally invasive debridement significantly improves treatment outcomes and lowers postoperative infection rates [30, 31]. This improvement can be attributed to the unique characteristics of the water flow, which effectively cleanses the wound, reducing bacterial adhesion and contaminants. Moreover, the water flow’s mechanical stimulation activates local fibroblasts and keratinocytes, promotes new blood vessel formation, and accelerates tissue regeneration [32, 33]. This technique reduces postoperative pain, leading to higher patient satisfaction. Since 2022, our department has provided standard surgical excision for facial burns [15, 34]. A cohort of patients treated with this method was randomly selected for the study (Table 4: 2010–2015). Our findings indicate that minimally invasive debridement effectively prevented infection, reducing the wound-deepening risk. Moreover, this method significantly shortened the healing time (12.26 ± 2.15 days) and lowered the VSS score (0.86 ± 0.84), compared to the standard surgical excisional technique (healing time: 14.51 ± 1.98 days; VSS score: 2.09 ± 0.70) (Table 2, p < 0.0001).

Table 4 Patient information for standard surgical excisional treatment (2010–2015)

These results underscore the hydrosurgery system’s potential to enhance healing outcomes for deep second-degree facial burns. Despite promising results, this study has limitations, including a small sample size and the absence of multicenter clinical validation, which may affect the generalization of the findings. Furthermore, the lack of comprehensive laboratory analysis limits insight into underlying mechanisms. Future research should include more extensive, multicentric trials and comparisons across burn types to validate these results further. This study presents a promising alternative for improving burn treatment outcomes, warranting additional investigation for broader clinical application.

Conclusions

Early minimally invasive debridement may accelerate wound healing, reduce scar formation, and enhance overall healing quality.