Anatomic sites need to be addressed as part of the whole injury, but also individually. With eye injuries, early closure and/or grafting must be considered. The eyelid skin is thinnest on the face, and early contracture can lead to exposure keratitis and rapidly destroy vision. An ophthalmology consult should be obtained because corneal abrasion is the most common injury. Protection of cornea with ointment or early tarsorrhaphies may be initially indicated. Ectropion may develop if secondary healing occurs with scarring or if tension occurs with primary closure. A graft of sufficient thickness should be used to help prevent lid contractures and globe exposure₅. Multiple surgical reconstructions may be anticipated until adequate function is achieved.

Mouth: Injuries around the mouth can be cause considerable deformities. Microstomia can be limited with the use of internal or external mouth spreaders upper and lower lip grafts can be placed to reconstruct the vermilion. Mucosal advancement flaps can also be used. Secondary reconstruction may be necessary, including scar releasing procedures.

Nasal: The skin is often preserved over the lower portion where the skin is thicker and the sebaceous glands are deeper. Flattening of the alar region is often encountered secondary to contracture.₄

Ear: Ear injuries may need local debridement or resection. If a choridritis occurs, it can be managed by removal of the affected cartilage. Attempts to salvage visible cartrilage may be made by burying in soft tissue pockets and later performing secondary graft reconstruction. Some patients may require local regional temporalis facial flaps for coverage. Pressure should be kept off the pinna with a doughnut dressing to reduce the possibility of pressure necrosis.₅

Tongue: It may produce coagulation necrosis of superficial tissue that appears whitish. In some cases, there may be frank ulceration and stripping of mucosa. Red area is tender to painful; it may blanch on pressure and there is bleeding on manipulation. It can be manage by systemic analgesics and topical hydrocarbon in emollient base.₆

Lip: There is persistent swelling and redness. It occurs due to prolonged contact of ice cream and other frozen confectionaries or very cold metal, glass object, with child's lip.₇

It must be determined if gases inhalation occurred. Signs suggesting inhalation injury are as follows: history of confinement at a burning building, exposure to an explosion, decreased level of consciousness, carbon deposits around the mouth or oropharynx, coughing, signed facial hair and respiratory distress. Assessment for carbon monoxide (CO) poising is imperative because this is most common cause of death in fires. The signs and symptoms of CO poising correlate with concentration. The symptoms is mild, throbbing headache, excitement, reckless behaviour, nausea, vomiting and fainting in exertion are observed. If the CO level rises above 50 percent, coma, convulsions or death may occur. One way observe the “cherry red” mucous membrane with increased CO, but this is not an absolute sign. The definitive test for CO poising is a spectrophotometric determination. Treatment is administration of 100 percent O2. If upper airway injuries are expected, one must consider the need for a controlled airway. Edema may increase over the first 24 to 36 hours and nasotracheal intubation or tracheostomy may need to be performed. The status of immunization must be noted and tetanus toxoid is not needed if the patient has been immunized within the past 5 years. Estimation of total surface area burned to helpful for fluid replacement. Wallace's rule of 9 is a reliable method for estimating the total body surface area burnt.

Management of first degree and minor second degree consists of suntan lotions, topical anesthetic, anti-inflammatory agents and oral antihistamines. Management of second degree of 15% or less or third degree of less than 2% of the body surface may be treated on an outpatient basis if all other circumstances are favorable.₉ Second degree and third degree burns of greater than 15 percent should be treated as in patients because plasma loss will be great enough to cause hypovolemic shock if not prevented by intravenous infusion. Burn greater than 30 percent should be treated at burn facility. Fluid replacement is estimated by the parkland formula.₁₀ To avoid overhydration and pulmonary edema, patients with inhalation injury should have their urinary output monitored closely. Deep second degree and third degree burns require surgical intervention unless the wound is small enough to heal by contracture. Initially, the wound is treated with either the exposure method or closed method.₉ Topical antimicrobial agents such as mafenide, silver sulfadiazine and 0.5 percent silver nitrate solution may be used to limit proliferation of bacteria. Systemic antibiotics may not reach the wound well and are not routinely used. Once patient is diagnosed with deep second degree or third degree injury, definite treatment must be considered. Numerous methods are available for wound reconstruction including; healing by granulation, freeskin grafts, primary closure, and local, regional or distant skin flaps.₁₁

For most oral and maxillofacial injuries, a sequential excision consisting of removing thin layers as injured tissue is performed until viable tissue is identified. A facial excision consists of removal of all tissue to the depth of underling muscle. This may be performed with a surgical blade or dermatome. After removal of non viable tissue, a graft must be placed and autogenous skin grafts are accepted as the treatment of choice. Donor sights of good quality of for the face are the scalp, neck, supraclavicular region, and inner thigh / arm. The autograph thickness can be variable, but a graft of 0.010 to 0.0025 inches in sheets seems to give good cosmetic and functional results.₁₂ Currently, a skin substitute called interga is available. It is a bilayer of pseudodermis with an overlying silastic cover. It contains no living components but supplies a protective covering and pliable scaffold onto which the patient's own skin cells “regenerate” the lower dermal layer that was destroyed by burn₁₃. Another material much like integra is alloderm. This material skin is produced by removing from cadaver skin all cell components that cause rejection. Similar to derm provides a scaffold for new derm's to form.₁₄ Other techniques to limit scar contracture are exercise, traction, oral appliances, nasal vestibule inserts, silicone sheeting and steriod injections.