burns 41 (2015) 1268–1274

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Preliminary results in single-step wound closure

procedure of full-thickness facial burns in children
by using the collagen–elastin matrix and review of
pediatric facial burns§

Mehmet Demircan *, Tugrul Cicek, Muhammed Ikbal Yetis

İnönü University School of Medicine, Department of Pediatric Surgery, Pediatric Burns Center, Malatya 44315, Turkey

article info abstract

Article history: Background: Management of full-thickness facial burns remains one of the greatest chal-
Accepted 14 January 2015 lenges. Controversy exists among surgeons regarding the use of early excision for facial
burns. Unfortunately, delayed excision of deeper burns often results in more scarring and
Keywords: subsequent reconstruction becomes more difficult.
Burns A collagen–elastin matrix is used to improve the quality of the reconstructed skin, to
Facial burns reduce scarring and to prevent wound contraction. It serves as a foundation for split
Dermal substitution thickness skin graft and enhances short and long-term results.
Scar formation Aim: We report the usage of a collagen–elastin matrix during single-step wound closure
Collagen–elastin matrix technique of severe full-thickness facial burns in 15 children with large burned body surface
Children area, and also we review the literature about pediatric facial burns.
Results: There were 15 pediatric patients with severe facial burns, 8 girls and 7 boys ranging
in age from 10 months to 12 years, mean age 7 years and 6 months old. The facial burn
surface area (FBSA) among the patients includes seven patients with 100%, five with 75%,
and three with 50%. The average total body surface area (TBSA) for the patients was 72%,
ranging between 50 and 90%. 5 of the patients’ admissions were late, more than four days
after burns while the rest of the patients were admitted within the first four days (acute
admission time). The burns were caused by flame in eight of the patients, bomb blast in four,
and scalding in three. All patients were treated by the simultaneous application of the
collagen–elastin matrix and an unmeshed split thickness skin graft at Turgut Özal Medical
Center, Pediatric Burn Center, Malatya, Turkey. After the treatment only two patients
needed a second operation for revision of the grafts. All grafts transplanted to the face
survived. The average Vancouver scar scales (VSS) were 2.55  1.42, ranging between one
and six, in the first 10 of 15 patients at the end of 6 months postoperatively. VSS measure-
ments of the last 5 patients were not taken since the 6 months postoperative period was not
over.
Conclusion: In regard to early results, graft quality was close to normal skin in terms of
vascularity, elasticity, pliability, texture and color. Esthetic and functional results have been
encouraging.

§
This paper was presented at 15th European Burns Association Congress held in Vienna on August 28th–31st, 2013 and at ISBI 2014 held
in Sydney on October 12–16, 2014.
* Corresponding author. Tel.: +90 422 3774009; fax: +90 422 3410728.
E-mail address: profdemircan@yahoo.com (M. Demircan).
http://dx.doi.org/10.1016/j.burns.2015.01.007
0305-4179/# 2015 Elsevier Ltd and ISBI. All rights reserved.
 burns 41 (2015) 1268–1274
This study shows us that the collagen–elastin matrix as a dermal substitute is a useful
adjunct, which may result in quick healing with satisfying esthetic and functional results.
It also may enhance short and long-term results in after burn facial wound closure in
children.
1. Introduction
Full-thickness burns to the face represent one of the most
difficult challenges for burn surgeons and often have
unsatisfactory outcomes. Poor skin quality and scar formation
are well known problems in facial regions. Facial burns are
devastating to a child, with significant physical and psycho-
social consequences. Facial burns and subsequent scar
formation can drastically affect the growth potential of a
child’s face [1–5].
Many of the treatment options for the adult patients with
burns are also applicable to children; however there are some
important differences to take into account. Compared with
adults, children’s facial skin has a greater density of dermal
appendages. This may lead to faster re-epithelialization and
improved wound healing in the context of burn. However, this
robust capability to regenerate may lead to either beneficial or
detrimental consequences. In some children, the cellular
mechanisms of wound healing will over-compensate, causing
hypertrophic scarring and devastating contractures in chil-
dren with severe facial scarring [1].
In addition, in cases of extensive burns, there may not be
adequate donor sites to allow for autograft harvest. Therefore,
there is a need for improvement in the management of facial
burns [3–6].
The use of dermal substitutes is an appropriate way to
minimize scar contraction and, thereby, to optimize the
quality of reconstructed skin. However, these dermal sub-
stitutes are associated with two-stage procedures due to the
increased distance between the wound bed and the skin graft
and the presumed diminished take rate of the skin graft [4,5,7–
10]. One of these substitutes consists of collagen and elastin
matrix and serves as a scaffold or a foundation. It has proven
to be suitable for a single grafting procedure in the critical sites
of the body such as soft tissue, neck, hands, feet, etc. [10–12].
Only case reports are present in the literature about using
collagen–elastin matrix in reconstruction of the deep facial
burns in adult patients [8,10,13].
In this study, we present the preliminary results of the
collagen–elastin matrix application during single-step wound
closure procedure of severe full-thickness facial burns in 15
children with large TBSA. In addition we review and summa-
rize the literature about pediatric facial burns.
2. Materials and methods
2.1. Patients
Between September 2012 and March 2013, 15 children, 8 girls
and 7 boys with ages ranging between 10 months to 12 years,
1269
# 2015 Elsevier Ltd and ISBI. All rights reserved.
with full-thickness facial burns were treated with a single-
step procedure. This procedure included early excision of
wound, implantation of 1 mm-thick collagen–elastin matrix
(Matriderm1, Dr. Suwelack AG, Billerbeck, Germany) on
wound and grafting by unmeshed split thickness skin at
Turgut Özal Medical Center, Pediatric Burn Center, Malatya,
Turkey. The bovine-derived collagen elastin matrix is a three-
dimensional matrix composed of native structurally intact
type 1, 3 and 5 collagen fibrils and elastin to support dermal
regeneration.
Our strategy consisted of treating the burn wounds
routinely with silver sulphadiazine 1% tulle cream before
early excision and grafting. The Facial burn depth assessment
was performed during surgical debridement on the sixth day,
after burn, if the patient was admitted acutely to our center or
as soon as possible if the patient admission was late. After full
removal of scab, necrotic and scar tissues of the full-thickness
burn wounds on the face by surgical debridement and after
hemostasis, the collagen–elastin matrix was implanted on
those areas (Fig. 1). Simultaneously split-thickness grafts were
applied as an unmeshed sheet and overlapped the wound
margin slightly on the same wounds. Split-thickness grafts
were fixated with sutures or staples. Five layers of paraffin
gauze, 4 layers of bulky gauze dressing and tight bandaging
was used to cover the autograft. The dressings were changed
for the first time postoperative on the 4th day. The staples
were removed, usually, on postop 8–10th day during other
operations for other burn sites.
Since all the patients in this series had more than of 50%
TBSA burns, 25% of TBSA of burn wound was excised in one
sitting. If two or more stages were employed, the entire face
with eyelids was excised and grafted over collagen–elastin
matrix in the first stage.
In this series, we used metal staples on the face of the
children. The use of staples did not affect the number of total
operations in the patients, due to combining the operations
with operations for other burn sites.
The Vancouver scar scales was assessed in the first 10 of 15
patients during their 6 months follow up appointment. The
last five patients, due to their shorter than 6 months
postoperative time, were not assessed. The VSS assessments
were performed by the same surgeon who operated on the
children.
Patients were eligible if they were admitted for surgical
treatment for burns. All legal representatives gave informed
consent before surgery.
2.2. Scope and goal of literature review of pediatric facial
burns
In this review an initial literature search was performed
in PubMed Entries with the following search terms:
1270 burns 41 (2015) 1268–1274
Fig. 1 – Appearance of the patient (#3) just after application of the collagen elastin matrix. (A) Severe burn on total face of patient
(#3). (B and C) Appearances of face at postoperative 6 months (#3).
‘‘pediatric facial burns treatment; pediatric facial burn
reconstruction; children face burns reconstruction; dermal
substitution and pediatric burns; dermal substitution and
pediatric facial burns; scar formation and pediatric burns,
scar formation and pediatric facial burns; xenografts and
pediatric burns; allografts and pediatric burns; MatriDerm
and pediatric burns; collagen–elastin matrix and pediatric
burns; graft and pediatric burns; flaps and pediatric
burns’’.
Only publications from the year 1999 and onwards,
and in English language only, were considered for this
review.
The goal was to find literature describing the standard of
care in reconstruction of pediatric facial burns and the role of
conservative treatment, split thickness skin grafts (STSG),
flaps, xenografts and collagen–elastin matrix in the treatment
pediatric facial burns. This preliminary report will focus on the
advantages and disadvantages of the various treatment
options described in the literature with a specific interest in
full thickness (facial) burns in children. This report is not
intended to be an exhaustive source, but merely represents a
high level summary.
Articles on the treatment/reconstruction of burn scar
revisions were excluded from this review. Also, articles where
burns were only a part of the reconstruction for soft tissue
injuries were excluded as well.
3. Results
3.1. Patients’ results
Fifteen children (8 girls, 7 boys; mean age 7 years and 6
months-old, range 10 months to 12 years) with full-thickness
facial burns were treated with a single-step procedure which
included early excision of wound, implantation of collagen–
elastin matrix on wound and grafting by unmeshed split
thickness skin.
Table 1 presents the patients’ characteristics in general.
Burns were caused by flame (n = 8), bomb blast (n = 4) and scald
(n = 3). Patients injured by bomb blast were from Syria. In all
patients, total body surface area (TBSA) burnt was over 50%
and the average TBSA of patients was 72%, ranging 50–90%.
The majority of burns affected the face (n = 15), the trunk
(n = 15), upper limbs (n = 15), lower limbs (n = 14), hands
(n = 11), and the feet (n = 9).
There was 100% facial burn surface area (FBSA) in 7, 75%
FBSA in 5 and 50% FBSA in 3 patients with severe full-thickness
facial burns.
Five of the patients’ admissions were late (>4 days after
burns). 10 of the patients’ admission times were acute (first 4
days after burns). Patients with late admissions were from
Syria in where there was a nationwide conflict.
 burns 41 (2015) 1268–1274 1271

Table 1 – Patients’ characteristics.

No. Gender Age Causes Admission FBSA (%) TBSA (%) Operations Length of hospital
(day) for face/body stay (month)
1 Girl 7 Flame 1st 100 75 1/4 4
2 Girl 3 Flame 7th 75 60 1/4 4
3 Boy 5 Bomb blast 7th 100 80 1/6 6
4 Boy 4 Scald 1st 50 50 1/3 3
5 Girl 12 Flame 1st 75 55 1/3 3
6 Girl 9 Bomb blast 6th 100 75 2/3 3
7 Girl 2 Scald 1st 75 80 1/7 5
8 Boy 5 Scald 11th 100 60 1/3 3
9 Girl 6 Bomb blast 5th 50 75 1/5 5
10 Girl 10/12 Flame 2nd 100 50 2/2 2
11 Boy 8 Bomb blast 1st 75 90 1/4 4
12 Girl 3 Flame 1st 50 90 1/4 4
13 Boy 1 Flame 1st 75 65 1/2 2
14 Boy 2 Flame 2nd 100 85 ¼ 4
15 Boy 2 Flame 2nd 100 80 1/4 4
FBSA, facial burn surface area; TBSA, total burn surface area.

All of the grafts implanted on the faces of all patients were
alive. Only two patients needed a second operation for
revision of the grafts, because patients had some graft loss
due to patients’ harmful motions during postoperative days.
Preoperative and postoperative pictures of patients (#3 and #9)
are shown in Figs. 1A–C and 2A–C. The best results were
observed in patients with partial facial burns. Patients with
total facial burns also had good results. If we compare the
grafted areas and unburnt skin, a color mismatch occurs as
shown in Fig. 2. Even when the elasticity of skin is excellent,
contracting bands are noticeable in mouth opening (Fig. 2B).
Table 2 presents the Vancouver scar scales (VSS), of the first
10 of 15 patients at the end of postoperative 6 months. The
average VSS was 2.55  1.42 (ranging from 1 to 6 and).
3.2. Literature review results
The literature review results are summarized in Table 3 with
focus on approaches to full-thickness pediatric facial burns.
4. Discussions
Thermal injuries of infants are frequent and there has been no
sign of decline in the number of these injuries over the past
years. The majority (>90%) of children suffer from scalds [14].
Thermal burns represent approximately two thirds of the
pediatric burn cases and are more common in older children
[15] Scald injuries due to hot liquids or steam are common in
younger children majorly caused by household accidents or
abuse.
Early tangential excision of partial- and full-thickness
burns was first introduced by Janzekovic in the 1970s and is
currently the standard of care for management of non-facial
burn wounds. Early excision of burn eschar followed by wound
coverage with temporary skin substitutes or skin grafting is an
important step in order to minimize hypertrophic scarring,
improve cosmetic, and lead to lower rates of infection, and
shorter hospital stay [16]. Early excision also protects the zone
of stasis from compromise by removing the inflammatory
cytokines that are elicited by the presence of eschar.
Full-thickness burns on the face represent one of the most
difficult challenges for burn surgeons and often have
unsatisfactory outcomes. Many approaches to surgical man-
agement of the severely burned face are described in the
literature (Table 3) [1–3,6,11,13,17–33]. There is controversy
among burn surgeons regarding the use of early excision for
facial burns. Early excision and grafting of the face has been
challenging because of the difficulty in diagnosing the depth of
the facial burn and accurately predicting an individual

Fig. 2 – (A) Severe burn on half of face of patient (#9). (B and C) Appearances of face at postoperative 6 months (#9).
1272 burns 41 (2015) 1268–1274

Table 2 – Presents the Vancouver scar scales (VSS) which assessed in the first 10 patients at the end of postoperative
6 months.
No. Vascularity Pigmentation Pliability Height VSS score
1 Normal (0) Normal (0) Normal (0) <2 mm (1) 1
2 Normal (0) Normal (0) Normal (0) 2–5 mm (2) 2
3 Normal (0) Normal (0) Supple (1) 2–5 mm (2) 3
4 Normal (0) Normal (0) Supple (1) <2 mm (1) 2
5 Normal (0) Hypopigmentation (1) Normal (0) 2–5 mm (2) 3
6 Normal (0) Hypopigmentation (1) Normal (0) <2 mm (1) 2
7 Pink (1) Normal (0) Normal (0) <2 mm (1) 2
8 No score No score No score No score No score
9 Normal (0) Hypopigmentation (1) Contracture(5) Flat (0) 6
10 Normal (0) Normal (0) Normal (0) 2–5 mm (2) 2
# 1 3 7 12 23

patient’s long-term prognosis both functionally and estheti-
cally. The majority of facial burns are treated conservatively
with a moist regimen of topical antibiotics that heal the burns
within 3 weeks [6]. Unfortunately on the other hand, delayed
excision of deeper burns often results in more scarring and
subsequently secondary reconstruction gets harder. It has
been recommended to first treat a deep burn conservatively
for 7 to 10 days with topical antimicrobial agents and local
debridement to allow clear determination of nonviable tissue
and then proceed with tangential excision and skin grafting
[1]. The most problematic late outcomes have been identified
after facial grafting for full-thickness facial burns [5]. It has
been shown that early excision and grafting of deep facial
burns produces better cosmetic results than late grafting on
granulation tissue [7,8].
Collagen elastin matrix for dermal regeneration is an
acellular tissue substitute. The native structurally intact
collagen serves as an essential component of the new
extracellular matrix for the migration of cells and vasculari-
zation. The programmed thickness of collagen–elastin matrix
allows initial supply to the graft by diffusion and rapid
vascularization [34]. As the healing process advances, the

Table 3 – Review results with focus on full thickness pediatric facial burns.
Treatment option Advantages Disadvantages Source/reference
Conservative Wounds heal by themselves with good Significant scarring, not suitable [1,2,6,17,18]
functionality (=controversial, usually only for all burn wounds
in superficial or partial thickness burns)

Tissue expansion a supply of tissue, similar in color, structure, Expanders needed, Multiple [19,20,21,22]
and adnexal distribution expansions or surgeries, Limited donor sites
Excellent esthetic results High complication rate in the facial area

STSG Minimal surgical trauma, Limited donor Post-operative contracture and scarring [1,23,24,25]
site morbidities Hyperpigmentation
No functional restriction of donor site

Flaps Acceptable skin color, contracture is unlikely
Continuous adaptation with child growth
One report of no complications nor donor site
functional restrictions
Better pliability than STSG
Limited donor site availability [1,21,25,26,27,28]
Donor site scars
Can be too bulky for facial reconstruction
Functional restrictions at donor site
(e.g. Trapezius myocutaneous flap)
Need of expander (e.g. Trapezius flap)
!additional surgical procedure

Xenografts + STSG Unlimited quantities, no need for donor skin Cannot be used solely (only in [1,3,29,30,31]
Increased scar elasticity combination with STSG)
Near normal skin Most need 2 separate procedures
Very limited donor site morbidities due to Longer hospital stay due to 2 procedures
thin STSG Necessary number of reconstructive
Improved cosmesis surgeries (revisions) not decreased

MatriDerm +STSG Unlimited quantities, no need for donor skin Cannot be used solely (only in [11,13,30,32,33]
[data from general One-stage procedure possible combination with STSG)
burn articles] Grafting over bone and tendons possible No data for pediatric burns
Improved cosmesis
Ease of use
Improved scar elasticity, even after 12 years
Objective long term follow up data available
STSG: single stage skin grafting.
 burns 41 (2015) 1268–1274
fibroblasts produce their own collagen matrix while collagen–
elastin matrix is degraded. Experiences from a human clinical
trial on the treatment of punch biopsy wounds demonstrated
that collagen–elastin matrix is completely resorbed 6 weeks
after implantation [35]. Nowadays, dermal substitutes are
considered to play a more prominent role in burn surgery and
have shown to minimize hypertrophic scarring, contractures
and increase scar elasticity in acute burn wounds [9,10].
Clinical studies on the treatment of burn wounds showed that
the elasticity of the regenerated skin was significantly better
after 3–4 months with the combined use of collagen–elastin
matrix and split thickness skin graft, than wounds that were
treated with split-skin graft alone [4–9].
A randomized controlled trial of early burn excision and
simultaneous application of collagen–elastin matrix demon-
strated a significant improvement in skin elasticity. Collagen–
elastin matrix has also been used in the acute setting for hand
burn wound closure, where again the quality of the dermis
was highlighted and range of movement was improved [8–13].
We applied the same technique easily in our severe facial
burns.
Generally, the POSAS and VSS have been widely used for
scar assessment, but it is typically difficult to decide which
scar assessment scale should be used since each scar
condition and treatment method has to be considered [36].
The VSS, which is universally used for assessing scars caused
by burns, assesses and calculates sub scores in 4 categories
(i.e., vascularity, pigmentation, pliability, and height of the
scar) and aggregates the scores [37]. The Patient and Observer
Scar Assessment Scale (POSAS), which comprise on two
factors: an observer scar assessment scale and a patient scar
assessment scale [38]. This method is significant because it
includes subjective symptoms beyond the objective-oriented
attempts and emphasizes the importance of the subjective
symptoms of patients [36].
Because the majority of our patients in this series from
Syria and did not speak English or Turkish, we could have
missed patients’ subjective symptoms like pain, itching, color,
stiffness, thickness, and relief. That’s why we decided use the
VSS instead of the POSAS. For the first 10 patients we
estimated very low levels of the VSS, averaging 2.55  1.42
(ranging from 1 to 6). In particular, elasticity of the faces was
very good in all patients. Most of the patients got a flat skin and
no patients got any ropes or contracture during pliability
examination except one. The vascularity and pigmentation
were normal in most of patients. Although this work is not a
comparative study, we think that these results obtained are
very important and promising. On the other hand, our
experience on grafting without using dermis substitution in
severe facial burn was very troublesome, especially, due to low
graft survival and bad elasticity results. It has been demon-
strated that the elastin component improves the stability and
elasticity of the regenerating tissue. Moreover, reduced wound
contraction has been observed in both an animal and a human
study [10–13]. At this point, our results also support this role of
the elastin component in collagen–elastin matrix.
When we see patients’ characteristics in our series, total
body surface area burnt (TBSA) was over 50% and the average
TBSA of patients was 72%, ranging 50–90%. This means that
donor sites were very limited in almost all patients. We were
1273
planning to cover the face at first step by ‘‘very thin’’ split
thickness skin graft, and were more sensitive about the graft
survival in such patients with very large TBSA.
This is the first series using the collagen–elastin matrix for
primary single-step burn wound closures on the face of the
children. We believe that this procedure can be performed
safely and results in improved cosmetic and functional skin
quality compared to alternative techniques. The proven
benefits of increased skin pliability and function in hand
reconstruction clearly show themselves in facial burn surgery.
Although our findings represent relatively early results, we
feel that this is likely to offer a useful and reliable tool for
challenging wound closure in the future.
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