Burn head. Management of Head and Neck Burns: Comprehensive Guide to Treatment and Recovery

What are the critical steps in managing head and neck burns. How can severe complications be prevented. What are the latest advancements in burn treatment and reconstruction techniques. When should medical attention be sought for burn injuries.

Understanding the Severity of Head and Neck Burns

Burns to the head and neck region are particularly concerning due to their potential impact on vital structures and functions. These injuries require prompt and specialized care to minimize complications and optimize recovery outcomes.

How are burns classified? Burns are typically categorized into three degrees based on their severity:

• First-degree burns: Affect only the outer layer of skin (epidermis)
• Second-degree burns: Damage extends to the dermis layer
• Third-degree burns: Penetrate through all layers of skin and can affect underlying tissues

The extent of the burn, measured as a percentage of total body surface area (TBSA), is a crucial factor in determining the appropriate treatment approach and potential risks.

Immediate Response and First Aid for Head and Neck Burns

Proper first aid can significantly impact the outcome of burn injuries. What steps should be taken immediately after a burn occurs?

1. Remove the person from the source of the burn
2. Cool the burned area with cool (not cold) running water for at least 20 minutes
3. Remove any clothing or jewelry near the burned area, unless it’s stuck to the skin
4. Cover the burn with a clean, dry cloth or sterile gauze
5. Avoid applying ice, butter, or other home remedies directly to the burn

For chemical burns, it’s crucial to flush the affected area with copious amounts of water for an extended period while seeking medical attention.

When to Seek Emergency Medical Care for Burns

Recognizing when professional medical care is necessary can be life-saving. Emergency medical attention should be sought immediately if:

• The burn is larger than the size of the person’s palm
• The burn appears to be third-degree (white, charred, or leathery appearance)
• The burn affects sensitive areas such as the face, hands, feet, or genitals
• There are signs of inhalation injury (difficulty breathing, singed nasal hair)
• The person shows signs of shock (pale, clammy skin, weakness, blue lips)
• The burn is caused by chemicals or electricity

Even for seemingly minor burns, medical evaluation is advisable if pain persists beyond 48 hours or if there are signs of infection.

Advanced Medical Management of Head and Neck Burns

Upon arrival at a medical facility, what can a burn victim expect in terms of treatment? The initial assessment follows the ABCDEF protocol:

• Airway management
• Breathing and ventilation
• Circulation and fluid resuscitation
• Disability (neurological status)
• Exposure and environmental control
• Fluid resuscitation

For severe burns, treatment may include:

• Intravenous fluid administration to prevent shock
• Pain management and sedation
• Wound cleaning and debridement
• Application of antimicrobial dressings
• Tetanus prophylaxis
• Nutritional support
• Monitoring for and treating complications

Airway Management in Head and Neck Burns

Why is airway management crucial in head and neck burns? Inhalation injuries and facial swelling can rapidly compromise the airway. Early intubation may be necessary to secure the airway before significant edema develops. Continuous monitoring of respiratory function is essential throughout the initial treatment period.

Wound Care and Infection Prevention in Burn Injuries

Proper wound care is paramount in burn management to promote healing and prevent infection. What are the key components of burn wound care?

• Regular cleaning and debridement of dead tissue
• Application of topical antimicrobial agents
• Use of appropriate dressings to maintain a moist wound environment
• Frequent dressing changes and wound assessments
• Systemic antibiotics when indicated

Advanced wound care products, such as silver-impregnated dressings and biosynthetic skin substitutes, can enhance healing and reduce the risk of infection.

Recognizing and Managing Burn Wound Infections

Burn patients are at high risk for infections due to the loss of the skin’s protective barrier. Signs of infection include:

• Increased pain or tenderness around the burn
• Redness or swelling extending beyond the burn margins
• Fever or chills
• Purulent discharge from the wound
• Foul odor

Prompt identification and treatment of infections are crucial to prevent systemic complications and promote optimal healing.

Reconstructive Techniques for Head and Neck Burns

As burn wounds heal, attention turns to functional and aesthetic reconstruction. What are the primary goals of burn reconstruction in the head and neck region?

• Restoration of form and function
• Prevention of contractures
• Improvement of aesthetic appearance
• Enhancement of quality of life

Reconstructive techniques may include:

• Skin grafting
• Local and regional flaps
• Tissue expansion
• Microsurgical free tissue transfer
• Scar revision procedures

Advances in Tissue Engineering for Burn Reconstruction

How is tissue engineering revolutionizing burn care? Recent advancements in bioengineered skin substitutes offer promising alternatives to traditional grafting techniques. These products aim to provide a more natural healing environment and potentially reduce scarring. Examples include:

• Acellular dermal matrices
• Cultured epithelial autografts
• Composite skin equivalents

While still evolving, these technologies hold great potential for improving outcomes in severe burn cases.

Long-Term Management and Rehabilitation of Head and Neck Burns

Recovery from severe burns is a long-term process that extends well beyond the initial healing phase. What are the key components of long-term burn management?

• Physical therapy to maintain range of motion and prevent contractures
• Occupational therapy to regain functional independence
• Scar management techniques (compression garments, silicone sheets)
• Psychological support and counseling
• Nutritional guidance to support healing
• Regular follow-up with the burn care team

Rehabilitation goals are individualized based on the patient’s specific injuries and needs, with a focus on maximizing functional recovery and quality of life.

Addressing Psychosocial Aspects of Burn Recovery

The psychological impact of burn injuries, particularly those affecting visible areas like the face and neck, can be profound. How can healthcare providers support the mental health of burn survivors?

• Early integration of mental health professionals into the care team
• Providing access to support groups and peer counseling
• Addressing body image concerns and social reintegration challenges
• Offering resources for managing post-traumatic stress and anxiety
• Involving family members in the recovery process

A holistic approach that addresses both physical and emotional aspects of recovery is essential for optimal outcomes.

Prevention Strategies for Head and Neck Burns

While treatment advancements continue to improve outcomes for burn victims, prevention remains the most effective strategy. What measures can be taken to reduce the risk of burn injuries?

• Installing and maintaining smoke detectors in homes and workplaces
• Implementing safety protocols for handling hot liquids and chemicals
• Using appropriate personal protective equipment in high-risk environments
• Educating children about fire safety and burn prevention
• Ensuring proper storage and handling of flammable materials

Public awareness campaigns and community education programs play a crucial role in reducing the incidence of burn injuries.

Workplace Safety Measures for Burn Prevention

In industrial and healthcare settings, specific precautions are necessary to prevent burn injuries. These may include:

• Regular safety training for employees
• Proper labeling and storage of hazardous materials
• Implementation of emergency shower and eyewash stations
• Use of flame-resistant clothing in high-risk areas
• Establishment of clear protocols for handling potential burn hazards

Employers should prioritize burn prevention as part of their overall workplace safety program.

Future Directions in Head and Neck Burn Treatment

As medical science advances, new approaches to burn treatment continue to emerge. What are some promising areas of research in burn care?

• Gene therapy for enhancing wound healing
• 3D bioprinting of skin substitutes
• Stem cell therapies for tissue regeneration
• Advanced drug delivery systems for improved pain management
• Artificial intelligence applications in burn assessment and treatment planning

These innovative approaches hold the potential to further improve outcomes and quality of life for burn survivors.

The Role of Telemedicine in Burn Care

How is telemedicine impacting burn treatment? Remote consultation and follow-up capabilities are expanding access to specialized burn care, particularly in rural or underserved areas. Telemedicine applications in burn care include:

• Initial triage and assessment of burn severity
• Remote monitoring of wound healing
• Virtual consultations with burn specialists
• Coordination of care between local providers and burn centers
• Patient education and support for home-based wound care

As technology continues to advance, telemedicine is likely to play an increasingly important role in burn management.

In conclusion, the management of head and neck burns requires a multidisciplinary approach that encompasses immediate care, advanced medical treatment, reconstruction, and long-term rehabilitation. By understanding the complexities of burn injuries and staying abreast of the latest advancements in care, healthcare providers can optimize outcomes and improve the quality of life for burn survivors. Continued research and innovation in this field promise to further enhance our ability to treat these challenging injuries effectively.

Burns: MedlinePlus Medical Encyclopedia

Call 911 or the local emergency number if:

• The burn is very large, about the size of your palm or larger.
• The burn is severe (third degree).
• You aren’t sure how serious it is.
• The burn is caused by chemicals or electricity.
• The person shows signs of shock.
• The person breathed in smoke.
• Physical abuse is the known or suspected cause of the burn.
• There are other symptoms associated with the burn.

For minor burns, call your health care provider if you still have pain after 48 hours.

Call a provider right away if signs of infection develop. These signs include:

• Drainage or pus from the burned skin
• Fever
• Increased pain
• Red streaks spreading from the burn
• Swollen lymph nodes

Also call a provider right away if symptoms of dehydration occur with a burn:

• Decreased urination
• Dizziness
• Dry skin
• Headache
• Lightheadedness
• Nausea (with or without vomiting)
• Thirst

Children, older people, and anyone with a weakened immune system (for example, from HIV) should be seen right away.

The provider will perform a history and physical examination. Tests and procedures will be done as needed.

These may include:

• Airway and breathing support, including a face mask, tube through the mouth into the trachea, or breathing machine (ventilator) for serious burns or those involving the face or airway
• Blood and urine tests if shock or other complications are present
• Chest x-ray for face or airway burns
• ECG (electrocardiogram, or heart tracing), if shock or other complications are present
• Intravenous fluids (fluids through a vein), if shock or other complications are present
• Medicines for pain relief and to prevent infection
• Ointments or creams applied to the burned areas
• Tetanus immunization, if not up to date

The outcome will depend on the type (degree), extent, and location of the burn. It also depends upon whether internal organs have been affected, and if other trauma has occurred. Burns can leave permanent scars. They can also be more sensitive to temperature and light than normal skin. Sensitive areas, such as the eyes, nose, or ears, may be badly injured and have lost normal function.

With airway burns, the person may have less breathing capacity and permanent lung damage. Severe burns that affect the joints may result in contractures, leaving the joint with decreased movement and a reduction in function.

Management of burn wounds of the head and neck region

Management of burn wounds of the head and neck region. Management of the severely burned patient is ery often a challenge, not only due to major disturbances in anatomy and physiological processes, but also because the relatively low incidence of this pathology in both civilian and military practice results in care providers’lack of experience. The purpose of this educational document is to provide doctors confronted with these formidable trauma patients with basic management guidelines as well as some practical tips. In summary, and most importantly, these patients should be reated as any other multitrauma patient. First aid is essential and can be provided by non-medical staff. Initial medical nanagement should focus on the usual, familiar trauma algorithms of ABCDEF from the emergency management of evere burns (EMSB) manual’ or the ABCDEs of the manual of advanced trauma life support (ATLS)2 or advanced burn life support (ABLS). Medical care should proceed through the following steps – Step one: establish a reliable intravenous nfusion; step two: protect the airway; step three: establish and maintain a haemodynamic state compatible with sufficient organ perfusion in order to reduce aggravation of the burn wounds and increase overall survival likelihood; step four: provide analgesia with adequate sedation and provide anaesthesia for escharotomy, fasciotomy or other surgical injuries; step five: maintain normothermia; step six: feed the patient by starting enteral nutrition as early as possible; step seven: prevent infection using antiseptic wound management, systemic antibiotics and tetanus prophylaxis. All of these intricate steps require continuous reassessment and adjustment, but the existence of other wounds (blast injuries, penetrating and blunt trauma) even further complicates the management of burn casualties.

Advances in Head and Neck Reconstruction, Part II: Burns: Treatment and Outcomes

Several predictable facial deformities follow serious burns of the head and neck region; these include:

In addition, abnormalities of texture and pigmentation may cause concern, as well as focal hypertrophic or keloid scarring not associated with functional problems.⁴

Avoiding Scars

Although the scar is an inevitable consequence of conventional treatment, the application of tissue engineering has opened up the prospect of avoiding or at least significantly reducing scarring. Integra (Integra Life Sciences, Plainsboro, NJ), for example, is a commercially available product. It is extremely expensive but does enable surgeons to treat full-thickness skin defects in an unprecedented way. Integra is a synthetic product of biological components. It is a bilayer structure composed of a defined matrix of type I bovine collagen and chondroitin sulfate derived from shark cartilage. This matrix is covered with a layer of silicone. The material is placed onto a full-thickness defect and secured with sutures or staples. Macrophages invade the collagenous matrix and begin to biodegrade it. They recruit fibroblasts and endothelial cells, which follow the macrophages into the matrix. The fibroblasts replace the degraded matrix with autologous collagen, and the endothelial cells begin the process of angiogenesis. The pore and fiber sizes of the Integra matrix permit an element of control in the neomatrix formation, and after 3 to 4 weeks the Integra matrix is replaced with a new autocollagenous “dermal” matrix exhibiting organization and morphology that distinguish it from scar tissue. At this stage the silicone is removed, and an ultrathin “epidermal” autograft is placed on the newly formed dermis.

Figure shows the first time that Integra was ever used on a facial burn, this in 1996. This 5-year-old child sustained 85% body surface area (BSA) full-thickness burns and underwent excision of more than 60% BSA on day 1 and a further 15% BSA on day 5 postburn. This 15% included the face, and Integra was cut and pleated to contour to the face. The Integra was attached in aesthetic units and sutured in place. The patient subsequently died from a pneumococcal septicemia, but lessons learned from this case have been extremely valuable in subsequent cases. Another early case of Integra application to the face involved an 11-month-old girl who was an identical twin. Integra was placed on the left lower eyelid, and a full-thickness postauricular graft was placed on the left upper eyelid. Six-year follow-up showed very mild medial canthal webbing and slight textural change of the lower lid, but otherwise the patient was very happy with the outcome.⁵

Five days postburn, the full-thickness facial burn was excised and Integra applied in cosmetic units.

Another early “off-label” application of Integra was in the delayed presentation of a nitric acid burn (Fig. ). This patient was first seen 5 days postinjury, and there was obvious full-thickness skin loss over the forehead, nose, and cheeks. A full-thickness skin excision was performed and Integra applied. One-year follow-up shows that the shape of the nose remains undistorted, and where the Integra was used there was no hypertrophy. The patient has had no further reconstructive surgery after the acute intervention.

(A) This patient was assaulted with nitric acid and sustained full-thickness burns of the forehead, nose, and cheeks. (B) The burn was excised using needle-point diathermy; (C) the pattern of the excised skin is shown. (D–F) Follow-up photographs at 1 year show that the area reconstructed with Integra is a little red, but otherwise there are no associated contractures or deformity.

The application of Integra in patients with extensive deep facial burns has been more thoroughly assessed and has been recommended for such burns where other injuries limit thick autograft coverage. It has been suggested that Integra is not good for eyelids because of the delay in vascularization.⁶ For eyelids, there has been some debate about what to use in the acute phase. Although conventional practice has been to use split-thickness grafts in upper lids, ectropion, corneal exposure, and repeated grafting are common sequelae. A review of patients treated in a single center who had either split- or full-thickness grafts of the upper eyelids showed fewer complications in patients treated with the thicker grafts.⁷ As with so many aspects of acute and reconstructive burns, care for each patient has to be considered individually. If there are potential donor sites for full-thickness grafts that would not be needed elsewhere or at a later date, these should be considered in the acute stage for the upper eyelids. When the eyelids are totally destroyed, such debate is no longer applicable. Again, the case has to be considered in the context of available donor sites, and, even in the acute stage, free tissue transfer should be considered. Such situations are reported as cases rather than series, which reflects the uniqueness of each patient. The report by Thai et al described corneal protection with bilateral conjunctival advancement flaps, septal cartilage graft support, and free dorsalis pedis flap cover.⁸ The acute management of the exposed cornea has inspired many ingenious solutions, but in the absence of local tissue, it is inevitable that free flaps have been used, such as the radial forearm flap.⁹

The Scar as the Enemy

In the reconstructive phase, it is important to be able to understand and predict the behavior of the scarring. Scar tissue is plastic, but the plasticity is very different from that of skin. Scar tissue can be stretched and molded, but the timescale of the remodeling is extremely protracted. For example, Fig. shows a young boy who sustained full-thickness facial burns. As the grafts began to mature, contraction began to cause an ectropion of the right eye. An external splint was made of acrylic. This dynamic splint was worn for 1 year, and the follow-up view shows a complete restoration of anatomy with a full return of function.

This boy was involved in an explosion in a closed space and sustained deep burns of the hands and face. (A) The eyelids were spared, but contraction of grafts on the cheek was causing distortion of the right lower eyelid. (B) A facial mold was taken under general anesthesia, and (C) a dynamic acrylic splint was made. (D) The mask was worn continuously for more than a year, and the 18-month follow-up view shows complete restoration of anatomy purely from scar molding.

Late Sequelae of Burns of the Head and Neck

Table outlines the late sequelae in terms of complications and their management. The management focuses on “skin” and “scar.” The difference is a question of degree of abnormality. Some superficial burns will heal with little or no dermal damage and hence no resulting scarring, yet the skin may be red and sensitive to sun, strong soaps, and cosmetics. There may be pigmentary abnormalities. Advice must be given on how to prevent or not exacerbate problems; for example, using sun block, mild topical anti-inflammatory agents (hydrocortisone 1% cream), or hydroquinones. Moisturizing the skin is important to preventing chafing and cracking, especially around the lips. Such advice is also appropriate when the burn has been deeper and scar tissue is involved. A range of nonsurgical options is available to reduce the impact of the scar and also to make psychosocial adjustments, so that life with a scar is still meaningful and fulfilling (Table ).

Table 2

Management of Late Sequelae

Table 3

Nonsurgical Strategies for Dealing with the Late Sequelae of Burns

Surgical Options

Surgery to deal with complications of facial burns can be extremely challenging. As reconstructive surgeons, we consider an increasing degree of sophistication in techniques in our reconstructive ladder. We are, however, expanding laterally to involve adjunct techniques, which in combination can greatly expand the possible options for treatment of the complications (Table ). The challenge in reconstruction is less concerned with the technical aspects of the surgery and more with the decision-making process. Table reflects the reality that many surgeons face: the compromise between what is possible (i.e., what could be done) and what is practical (i.e., what should be done). This decision is a matter of surgical judgment and has to reflect several factors. The resources available may be plentiful or scarce. New materials, tissue-culture facilities, and operating microscopes may or may not be available. Even if such facilities are available, the expertise to use them to the best advantage may not be available. There may be problems with infection in the cell culture laboratory, or specialized equipment may have been donated or provided without necessary training in its use. In surgical reconstruction, the active involvement of the rehabilitation team is essential to achieve optimum outcome. In the absence of follow-up, there is no guarantee that all has gone well. Single procedures to address only the major problem can be considered. This reality is very different from the textbook ideal of multiple episodes of reconstruction, beginning with the essential functional procedure and ending with the “fine-tuning” procedures. An example of the former would be bilateral commissureplasties to improve the mouth opening; an example of the latter would be reconstruction of the philtrum.

Table 4

Surgical Strategies for Dealing with the Late Sequelae of Burns: The Reconstructive Ladder

Table 5

Protocol to Individualize Treatment for Burn Patients

Mention should be made of prosthetics and osseointegration, which can be remarkably realistic. Again, for reconstruction of the head and neck this is a resource-demanding technique. Other techniques that come under the category of the possible are scalp reconstruction with tissue expanders, laser resurfacing, and pigment reduction. In practical terms, we should recognize that after a severe burn of the head and neck we are dealing with a “renaissance.” We need surgery but also, very importantly, psychology. I have mentioned prosthetics, but cosmetics also need to be considered. Aesthetic enhancement can be achieved by waterproof long-lasting cosmetic creams and powders to restore texture and color to scarred skin. Even though cosmetics should not be used on a day-to-day basis, they are an option for special occasions.

Reconstruction of Specific Features

The following sections deal with reconstruction of specific features of the head and neck.

NASAL RECONSTRUCTION

The nose is the central feature of the face, around which eyes, ears, and mouth are arranged. As such, it represents a prime aesthetic feature, as well as serving an important functional purpose in breathing. The nose can be reduced in anatomic simplicity to cover and lining, with a structural framework comprising both bone and cartilage. The nose is a feature that has distinct racial differences, which can be described in terms of length, breadth, height, projection, and shape of the nares. The skin of the nose varies from tip to dorsum, being thickly sebaceous at the tip and thin and very pliable over the dorsum. Nasal reconstruction has to take into account all these features, and the essential process involves determining what is lost or missing and what is available to reconstruct or replace. Therefore, the reconstruction of the postburn face can often be considerably more challenging than that of both trauma and postoncologic resection because of the limited availability of local and/or near-local tissue. As in the reconstruction of other special features of the face, a full spectrum of techniques exists to address the wide spectrum of defects. Skin defects can be replaced with skin grafts, both split and full, as well as tissue-engineered skin substitutes. The challenges begin with contractures of scar, causing deformity of the shape of the nose. A common problem is the retraction of the ale margin, which necessitates replacement of both cover and lining. This can be achieved with a composite graft from the helical rim, if the rim has not been damaged (Fig. ). Alternatively, the scarred external skin can be advanced to form the new lining and a graft or flap cover can be applied to the outer defect. With loss of more of the structure of the nose, more extensive procedures have to be considered, including the classic forehead flap with or without tissue expansion,¹⁰ the distant pedicled flap,¹¹ and free tissue transfers.¹² Nasal reconstruction is a complex procedure that may involve multiple stages to transfer tissues, rebuild the support, and refine the shape (Fig. ). Ultimately, however, it is worth the time and effort to achieve the best possible result because of the central importance of the nose in facial aesthetics. As in other aspects of burn reconstruction, it is essential to listen to the patient and operate only if that is the patient’s wish.

This series of pictures shows the healing of composite grafts applied to both right and left ala margins at 2 week intervals. (A) Two weeks postoperation. This underlines the importance of not rushing in to debride failed grafts. The problem is that the scar bed and composite grafts take longer to revascularize. (B) Four weeks postoperation. (C) After 6 weeks, the alar rims are well formed.

This patient was the victim of an acid assault that left her blind. The scalp was expanded and advanced to cover bare bone on the forehead to provide a graftable bed. (A) New eyebrows are planned, and cover for the nose will be achieved with a free-style perforator flap from the left medial thigh. (B) The distal nasal skin is preserved to act as lining and the scarred dorsal skin excised. A tunnel is made to the left facial artery and vein. (C) The “crane” flap is excised from the forehead and some of the hair-bearing skin used for eyebrows. The defect was closed with a sheet graft and the free flap inset. (D) The patient 2 weeks later with the nasal dorsum covered with a light hydrocolloid gel where she places her glasses. The nose will need to be thinned in stages but already the patient is pleased with the texture compared with the previous scarring. This is an important dimension to consider when operating on blind patients.

THE EAR

In considering the reconstruction of the ear postburn, the focus is primarily on the external ear as well as the patency of the external auditory meatus. The goal for external ear reconstruction is to restore the function of the helical rim, to provide support for spectacles, and also to present a cosmetically acceptable auricle. The significance of ear deformity will vary with custom and culture, and patients are more generally willing to accept ear deformity than, for example, nose deformity perhaps due to the ability to conceal more readily. The ear represents a complex intrinsic anatomy, but a major contribution of the ear to the aesthetic completeness of the patient is the relative position and orientation of the ear in relation to other facial features. This is particularly evident when facial scarring pulls the ear anteriorly and into a more vertical position (Fig. ). Another point to establish in analyzing the postburn ear is to determine the nature and the extent of the tissue lost. Unfortunately, in acute burns care, protection of the ears is often neglected, and the helical rim can be pulled forward and adhere with scar to the preauricular area. In these situations, restoring the major components of the ear to their original position and using local flaps and applying skin grafts may suffice to give an acceptable appearance.¹³ As the destruction and deformity of the ear become more extensive, so the reconstructive challenge becomes greater. The extreme is the total or almost total loss of the external ear, leading to the question of complete reconstruction or replacement. The options of autologous or non-autologous tissues have to be considered.¹⁴ In simplest terms, the ear is a sandwich of skin, cartilage, and skin. The availability of skin for autologous reconstruction may be a problem in the postburn patient, although it can be imported on a free tissue transfer with a prefabricated ear.¹⁵ An alternative is temporal fascia covered with graft. Judicious use of skin expansion can create enough for this pliable cover. If local tissue is not available, a variety of free fascia-only flaps are reasonable to use. The skeleton can be constructed from autologous cartilage or foreign materials, such as Medpor (Porex Corporation, Fairborn, GA) porous polyethylene framework. The considerable challenge must be appreciated by both surgeon and patient. In this situation, osseointegration may be feasible.

(A) This girl has had severe burns to the right side of the face, and (B) the right ear has been pulled forward by the scarring on the right cheek. (C) This is particularly evident in this patient as the left side is completely unscarred showing the normal orientation and placement of the ear. (D) This young boy has sustained severe facial burns and has a marked microstomia. (E) The right ear has not been badly damaged, but lack of attention in the acute phase has left the helical rim fused to the cheek with scar tissue. Simple release and minor grafting will restore an acceptable ear. (F) The left ear is more significantly burned, but the cartilaginous scaffold is still salvageable.

THE NECK

The neck comprises a surprisingly large area of skin. The anatomic structure of the neck enables the extensive range of flexion, extension, rotation, and lateral tilting on which the normal person relies. The most common postburn problem is a flexion contracture of the neck. A range of surgical procedures can address this problem, encompassing the full extent of the reconstructive ladder. Split-thickness grafts can cover the extensive defects created after scar release. These grafts will need meticulous attention to achieve complete and early wound closure, but thereafter prolonged splintage will be important to maintain release and prevent recontracture. Flaps will be better in maintaining release and reducing the need for further surgery. Flaps may be raised locally with or without prior expansion. Pedicled flaps, particularly the latissimus dorsi myocutaneous flap, can create permanent and effective release.^16,17 Free flaps again can provide excellent functional and aesthetic results that are long lasting.^{18,19,20,21,22,23,24} Such procedures, however, need to be carefully planned and skillfully executed to achieve optimum results. Thinning of flaps to be used in the neck is a feature allowed by the anterolateral thigh flap, although prior expansion can also create suitably thin flaps when harvested from other sites, including groin and scapula.^25,26,27 Thinning alone will not guarantee a good result. One neglected aspect of flap inset is the avoidance of straight lines (Fig. ), which can give rise to both contractures and webbing but also to pin-cushioning effects in encircling scars.²⁸

(A) This patient was referred with an extremely foreshortened neck after sustaining facial burns and having the neck skin grafted. (B) A radial forearm flap was expanded using an externalized port on the patient, who had needle phobia. (C) After releasing the neck scar, a 10 × 12 cm defect was created (D) that was filled by the flap. (E ) Five years later, the patient presented with some tightening of the left side of the neck associated with the linear flap inset. A free-style perforator flap was raised from the leg and inset with a W-shape to release the scar. The inset shows the original preoperative view, in particular the deformed left ear.

If flaps are too thick, recontouring procedures need to be considered. The choice is between an open defatting that is staged or a closed liposuction approach. Both surgeon and patient need to appreciate that one-stage reconstructions of complex functional and aesthetic anatomy can rarely be achieved, and the need for “fine-tuning” and revisionary procedures must be considered.

Another technique in neck reconstruction that has been used to good effect is Integra, the dermal regeneration template. With Integra, as with split-thickness skin grafts, a period of postoperative splintage must be ensured, as contraction is likely to reoccur.²⁹ The neck together with the chin in combination should be considered from an aesthetic perspective, particularly with regard to the projection of the chin, which can be corrected with genioplasty,³⁰ and the postburn mentosternal angle.³¹

THE FACE

The human face is a complex blend of textures and contours. The major contributors to the contours are the underlying bony skeleton and the deposition of fatty tissue, while the skin provides the texture. In the majority of burns, particularly thermal burns, most damage is restricted to the cutaneous aspects of the face. The acute care will have a significant influence on the resulting scarring. The extent and nature of the scar will determine the reconstructive need. Hypertrophic scar is associated with contraction, which leads to distortion of the mobile features of the face, in particular the eyelids and the lips. Restoration of anatomic positioning will require removal of the contracting force associated with the scar, by either excision or incision of scar. Either process will create a defect that then needs to be filled. This, then, is the principle of facial reconstruction, which in practice will be influenced by the resources, expertise, and experience of the reconstructive team. From the aesthetic perspective, the face is generally considered in units, and addressing a unit in its entirety is preferable to replacing part of a unit. The aim is to try to restore the face to a wholesome normality, with features that blend into each other, and to avoid an eye-catching patchwork of textures.

Figure portrays the main aesthetic units of the face and also gives an indication of aesthetic proportions, with the face being five eye-widths wide and eight eye-widths high. The eyes are one eye-width apart, and the alae nasi span one eye-width. The mouth is wider than the nose, typically in a nose-width to mouth-width ratio of 1:1.618. This ratio of 1.618, known as phi (ϕ), is a basic unit of aesthetic relationship present throughout nature.³²

(A) The major aesthetic units of the face are shown together with a variety of strategies for cover. SSG, split-thickness skin graft; FT, full thickness; TEx, tissue expansion. (B) When there is deeper damage, then more complex reconstruction is necessary, especially for the nose and ear.

The various units can also be regarded differently from the reconstructive perspective; an important consideration is whether the unit is fixed or mobile. In this respect, the forehead can be regarded as a fixed unit, and split-thickness grafts can be used with confidence that there will be little contraction and distortion or deformity of adjacent features. Such grafts, when applied as sheets, can look unnaturally smooth and shining, and the application of a closed mesh may give a duller surface to the skin. The forehead is also a good site for Integra, as it allows a rigid fixation during the stage of biointegration and vascularization and also is not prone to contraction in the remodeling phase.

The chin and cheeks provide another challenge, as they are not only more mobile but also are adjacent to mobile structures (i.e., the eyelids and lips). Reconstruction is often required when there is the need to release contractures and correct deformity. Again, the reconstructive ladder has to be considered, together with the available local and distant tissues. For the cheek, skin grafts, particularly full-thickness ones, can give a very pleasing appearance in terms of texture and movement. Large amounts of skin may be needed, which can be achieved by using prior skin expansion.³³ However, these grafts can be extremely technically demanding, and the overall success can be marred by a small percentage of graft loss. Limited facial scarring in the lower third of the face can be excised and defects closed by advancement of unburned neck skin. This is not unlike a reverse face-lift procedure, with extensive undermining of neck skin being performed. Such skin can be advanced even higher if there has been prior tissue expansion. Advancing tissue-expanded skin too high, however, is associated with a tendency for the skin to retract, causing scar widening or ectropion. Extreme overexpansion is necessary,³⁴ and suture suspension of flaps should be considered.³⁵ An alternative is to consider pedicled flaps; one particularly useful for replacement of the lower two-thirds of the face (Fig. ) is the expanded supraclavicular artery flap.^19,36 Pedicled, expanded, and prefabricated flaps, which have received considerable attention in postburn facial reconstruction, have involved several novel techniques, including prefabricated, induced, and expanded flaps^37,38 as well as prelining flaps.³⁹ The range of flaps used is extensive, but attention has to focus on color match and texture, as in the retro-auriculotemporal flap,⁴⁰ as well as adaptability. In the latter respect, the dorsal scapular artery flap can be used as a pedicled flap for facial reconstruction. The flap can be both delayed and expanded to increase its versatility and robustness.⁴¹

This boy is the same patient who appeared in Fig. . (A) The mouth has been opened, a priority when a series of procedures is planned to facilitate anesthesia. The unburned skin in the supraclavicular region makes this an ideal case for creating new full-thickness skin by tissue expansion. (B) Bilateral expanders have been inserted and will be overexpanded to reduce the impact of retraction after positional transfer.

THE SCALP

Postburn alopecia can be graded according to the extent and density of the hair loss (Table ).⁴² This classification differs from classifications of scalp burns.

Table 6

Classification of Burns Alopecia

For types I and II alopecia, tissue expansion remains the most effective way to restore an acceptable distribution of hair. Tissue expansion is a technique that has many “tips and tricks” and can be highly rewarding in scalp reconstruction.^43,44 The appropriate size and shape of the expander must be chosen to allow optimum flap creation. Crescentic expanders can be useful for circular defects, but for linear defects rectangular or cylindrical expanders are better and certainly preferable to circular expanders (Fig. ). Antibiotics should be used prophylactically at the time of expander insertion, and the elevated pocket should be copiously irrigated with a dilute antimicrobial solution prior to inserting the expander. It is important to ensure that the pocket is large enough to accommodate the expander, particularly when the expander is in the deflated state in which the bone dimension is greater than in the expanded state. Incisions for inserting expanders should ideally be made through normal skin. If they are made radial to the main axis of expansion, the process of expansion can begin early, without a major concern about dehiscence. However, the flap that is going to be created and advanced must be considered; it may be necessary to make an incision parallel to the long axis of the alopecia. Shaving the hair in the region of the incision will decrease the possibility of introducing hair into the expander pocket. Prior to inserting the expander, the pocket should be inspected for bleeding points, as it is preferable to avoid insertion drains, which can theoretically cause trauma to the expander envelope when they are removed. The injection portal can be buried or left externalized. With appropriate care and attention, risk of infection does not appear to be increased with an externalized port. The expander pocket should be closed in layers, with particular attention being paid to avoid accidental puncture of the envelope. Once the wound is closed, the expander can be filled enough to tamponade any oozing within the expander cavity. This technique also allows the envelope to be “unfurled,” thus avoiding rolled edges or ridges.

This girl is the same patient who appeared in Fig. . (A) A crescentic expander has been chosen. (B) The three-dimensional computed tomography scan shows that there is no bone deformity in this 15-year-old girl although this can be a feature in younger children. Because the treatment of this patient has to be staged, she will require a second episode of expansion to extend the hair-bearing scalp into the right temporal region. (C) The postoperative view shows the restoration of the anterior hairline in the midline and also (D) the effect of a small postauricular flap transposition anteriorly that has given the ear a more normal appearance even though the ear itself was not touched.

Definitive expansion can begin when the wound used to insert the expander is stable enough not to dehisce during the expansion process. This will depend upon the association of the wound to the expansion forces.

The use of the endoscope certainly allows pockets to be created with smaller incisions, which can help reduce the interval between insertion and definitive expansion. The rate of expansion will be determined by the response of the skin and the patient. Generally, the process begins slowly, but thereafter regular weekly expansion can achieve significant incremental volumes to be inserted. As in all flap surgery, the size of flap needed should ideally be larger than the defect to allow for adjustments and inset. A period of rest should be allowed between the final expansion and the removal of the expander and transposition of the flap. This allows the expanded skin to achieve some stability so that it does not immediately shrink after the expander is removed. When insetting the flap, it is important to remember to avoid straight-line scars in hair-bearing skin. The judicious incorporation of Z-plasties will allow the narrow linear bands of alopecia to be suitably camouflaged.

For types III and IV alopecia, the choice for the patient is to wear a wig or, if male, to go with the bald look. This latter approach is quite acceptable for older patients but is a concern for children.

EYELIDS AND EYEBROWS

The eyelids have an extremely important functional role in protecting the cornea. At the same time, the eyelids have to move to allow for vision. The anatomic complexity of both upper and lower lids cannot be underestimated, and the challenges presented by eyelid reconstruction are formidable, particularly in the postburn patient. The most devastating burns to affect both eyes and eyelids are chemical burns. The depth and extent of destruction associated with these burns would only occur in otherwise lethal thermal injuries. The acute management of burns that affect the eyes and eyelids has to focus on preservation of the cornea at all costs. Thus, if eyelids are damaged or lost, the corneas may be covered with conjunctival flaps, which can then be covered with skin grafts. The use of autologous transplantation of nasal mucosa to reconstruct the fornices is associated with persistence of goblet cells, excess mucus, and protection of the globe.⁴⁵ Reconstruction of the tarsus has been successfully achieved with acellular human dermal allografts,⁴⁶ and more recently lower eyelids have been reconstructed with composite auricular grafts to maintain the shape of the globe and thereby reduce the incidence of opacification. ⁴⁷ Subsequent management of such devastating injury may involve the use of scleral lenses with a limited aperture. Dealing with such injuries is a very specialized branch of oculoplastic surgery and is beyond the scope of this article.

The more common deformities of the eyelids involve scar contraction resulting in ectropion of upper and/or lower lids or deformities of medial or lateral canthi.⁴⁸ The surgical management of ectropion involves an analysis of the deficiencies of the tissues and the distortion of the anatomy. Lower lid ectropion is often associated with distortion of the tarsal plate, which becomes more horizontal in orientation. Although the scar contracture can be released and indeed overcorrected with skin grafts, the tarsal plate will continue to be misshapen due to elongation. Full or very thick split-thickness grafts are used for the contracture release. The tarsal plate will need to be shortened and refixed with a lateral canthopexy to reposition the tarsal plate in a more vertical orientation. In the upper lid, ectropion is again corrected by scar incision and graft placement, but split-thickness grafts are more commonly used. In both upper and lower lid ectropion, it is important to extend the releasing incisions beyond the respective canthi so that the lid can be suitably released and the grafts fixed with the overdressings.

Medial and lateral canthal webs can be corrected with multiple Z-plasties, local transposition flaps, or both. As these folds rarely cause a significant functional problem, it is better to wait for scar maturation before considering correction.

Eyebrow reconstruction can play an important role in the restoration of aesthetic balance in the postburn face. Several options are available involving free and vascularized procedures. The use of free micrografts, minigrafts, and strip grafts is not always successful, in part because of the hostile scar bed. The best way to achieve a richly dense eyebrow is to use a pedicled vascular graft of scalp hair with a subcutaneous tunnel of a pedicle containing branches of the superficial temporal artery (Fig. ). Use of this technique can be limited by the distribution of alopecia if there are associated scalp burns.

(A) This patient was the victim of an acid assault but was taken immediately to the operating room for debridement. The benefits of this treatment are reflected in the reduced deformity of the deeper structures, particularly on the nose. The eyebrows and scalp were not showed immediately, and although the patient does not mind the patchy alopecia, which he disguises by shaving his head, he believes that loss of the major portion of the right eyebrow is a significant problem. (B) The course of the posterior branch of the superficial temporal artery has been identified using the hand-held Doppler giving an island of hair-bearing scalp. (C) This has been elevated and can be transposed via a subcutaneous tunnel.

LIPS AND MOUTH

The lips and the mouth are functionally important in achieving oral continence while eating and drinking and also in the production of intelligible speech. Aesthetically, the size and shape of the mouth, particularly when there is gross eversion of the lips, revealing the teeth, can be of major psychological concern to the patient. The two major deformities encountered are the small, contracted mouth and the large mouth with everted lips and associated scar contractures. The management of microsomia involves oral commissure reconstruction. This will involve recruiting buccal mucosa to effect a new lining of soft tissue after bilateral incisions are made to extend the commissures laterally. In addition, the buccal mucosa is used in vermillion reconstruction.

An excellent practical guide to oral commissure reconstruction appears in Achauer’s classic text.⁴⁹ Microsomia can be associated with oral cavity contractures, particularly in children. These cases are very difficult to treat, but scar release, skin grafting, and prolonged splinting (Fig. ) are the most common strategies employed.⁵⁰ If the area of scarring is localized, then excision and free tissue transfer can be considered. For the shortened and everted lip, the general management is as for the ectropion of the eyelids. The scar has to be incised and the position of the lip overcorrected, while a suitable thick split-thickness graft is inset and a tie-over dressing applied. There are, of course, several variations on this theme. Local flaps from the nasolabial area can be used if available, in conjunction with other pedicled flaps.^51,52 Expanded flaps can be brought up to fill defects created by scar excision. This is particularly advantageous in children: The incorporation of full-thickness skin together with this layer of adipose tissue will allow for growth and development and reduce the need for further surgery. Another situation when a flap can be effective is in the male patient with badly scarred or deficient lips. Hair-bearing flaps can be used to create either a new upper lip together with mustache, as in the visor flap⁵³ or in the hair-bearing submental flap, which can create a beard. ⁵⁴ As with other aspects of facial reconstruction, a major part of the challenge is to find and choose the most suitable donor sites and tissue transfer techniques if there is extensive scarring elsewhere in the body. To this end, such clinical techniques as using tube-pedicled flaps may occasionally be useful in such reconstruction. The surgeon involved with aesthetic and functional reconstruction of the postburn patient must be extremely versatile and proficient in an extensive range of reconstructive techniques, both old and new.

This series illustrates the unforgiving nature of burn scars. (A) A patient developed significant scar contraction in the early postburn phase and (B) a release achieved by bilateral commissureplasties, which gave both (C) an acceptable aesthetic result and (D) a functional result. The patient was provided with a splint and supervised on application and use. Eighteen months later, the patient presented with a significant recurrence of microstomia and no splint. (E, F) A re-release was performed to facilitate anesthesia, and bilateral neck tissue expanders were inserted to allow the scar to be excised and replaced.

First Aid Treatment for Thermal Burns

Call 911 if:

• The burn penetrates all layers of the skin.
• The skin is leathery or charred looking, with white, brown, or black patches.
• The person is an infant or a senior.

For All Burns

1. Stop Burning Immediately

• Put out fire or stop the person’s contact with hot liquid, steam, or other material.
• Help the person “stop, drop, and roll” to smother flames.
• Remove smoldering material from the person.
• Remove hot or burned clothing. If clothing sticks to skin, cut or tear around it.

2. Remove Constrictive Clothing Immediately

• Take off jewelry, belts, and tight clothing. Burns can swell quickly.

Then take the following steps:

For First-Degree Burns (Affecting Top Layer of Skin)

1. Cool Burn

• Hold burned skin under cool (not cold) running water or immerse in cool water until the pain subsides.
• Use compresses if running water isn’t available.

2. Protect Burn

• Cover with sterile, non-adhesive bandage or clean cloth.
• Do not apply butter, oil, lotions, or creams (especially if they contain fragrance). Apply a petroleum-based ointment two to three times per day.

3. Treat Pain

4. When to See a Doctor

Seek medical help if:

• You see signs of infection, like increased pain, redness, swelling, fever, or oozing.
• The person needs tetanus or booster shot, depending on date of last injection. Tetanus booster should be given every 10 years.
• The burn blister is larger than two inches or oozes.
• Redness and pain last more than a few hours.
• The pain gets worse.
• The hands, feet, face, or genitals are burned.

5. Follow Up

For Second-Degree Burns (Affecting Top 2 Layers of Skin)

1. Cool Burn

• Immerse in cool water for 10 or 15 minutes.
• Use compresses if running water isn’t available.
• Don’t apply ice. It can lower body temperature and cause further pain and damage.
• Don’t break blisters or apply butter or ointments, which can cause infection.

2. Protect Burn

• Cover loosely with sterile, nonstick bandage and secure in place with gauze or tape.

3. Prevent Shock

Unless the person has a head, neck, or leg injury, or it would cause discomfort:

• Elevate feet about 12 inches.

• Elevate burn area above heart level, if possible.

• Cover the person with coat or blanket.

4. See a Doctor

• The doctor can test burn severity, prescribe antibiotics and pain medications, and administer a tetanus shot, if needed.

For Third-Degree Burns

1. Call 911

2. Protect Burn Area

• Cover loosely with sterile, nonstick bandage or, for large areas, a sheet or other material that that won’t leave lint in wound.

• Separate burned toes and fingers with dry, sterile dressings.

• Do not soak burn in water or apply ointments or butter, which can cause infection.

3. Prevent Shock

Unless the person has a head, neck, or leg injury or it would cause discomfort:

• Elevate feet about 12 inches.

• Elevate burn area above heart level, if possible.

• Cover the person with coat or blanket.

• For an airway burn, do not place pillow under the person’s head when the person is lying down. This can close the airway.

• Have a person with a facial burn sit up.

• Check pulse and breathing to monitor for shock until emergency help arrives.

4. See a Doctor

• Doctors will give oxygen and fluid, if needed, and treat the burn.

How to Treat a Burn at Home (and When to Head to the Hospital)

Labor Day is right around the corner and millions of Americans will be firing up their barbecues to celebrate the unofficial end of summer. Grilling season can also be “burn season.” In 2014, over 8,000 Americans went to the emergency rooms with thermal burns as a result of a grill fire or accident while cooking outdoors.

Whether you sustain a burn from a grill or another heat source, you’ll want to know when to treat at home and when it’s better left to the professionals. To get the bottom of it, we teamed up with the special effects team at SyFy Channel’s Face Off and Dr. John Torres, NBC News Medical Correspondent, to create amazingly realistic burns, both minor and more severe, to show you how to treat a burn at home — and when you should head to the hospital.

Dr. Torres says that the majority of the burns he sees in emergency rooms don’t actually need professional medical attention. Here’s what you need to know:

When to Treat a Burn at Home

1. When you feel pain.
2. The skin is blanchable. This means the skin turns white when pressed and then red again.
3. The burn isn’t covering your hands, joints (think: knees or hips) or face.

How to Treat a Burn at Home

• Step 1: Remove any hot or burning material from the affected area.
• Step 2: Wash the area with soap and water.
• Step 3: Apply antibiotic ointment.
• Step 4: Cover with a gauze pad.
• Step 5: Wrap with a roll of gauze and secure with adhesive tape.

Related

When to Head to the ER to Treat a Burn

1. The burn is deep and the skin is peeling.
2. There is little or no pain.
3. It’s covering your hands, joints or face.

If you have any of the symptoms above, go to the ER immediately for professional treatment to avoid infections and scarring. “Those are the two biggest things we worry about when it comes to deep burns,” says Dr. Torres.

If you decide to treat a minor burn at home, call your doctor if you feel any of the following symptoms:

• The pain gets worse or more frequent.
• Signs of infection are evident.
• Any other related symptoms you may be worried about.

Want more tips like these? NBC News BETTER is obsessed with finding easier, healthier and smarter ways to live. Sign up for our newsletter.

Burn Treatment & Prevention Tips for Families

​There are many different causes of serious burns in children, including sunburn, hot water or other hot liquids, and those due to fire, electrical contact, or chemicals. All of these can cause permanent injury and scarring to the skin.

Immediate Treatment Steps for Burns:  

1. As quickly as possible, soak the burn in cool water. Don’t hesitate to run cool water over the burn long enough to cool the area and relieve the pain immediately after the injury. Do not use ice on a burn. It may delay healing. Also, do not rub a burn; it can increase blistering.

2. Cool any smoldering clothing immediately by soaking with water, then remove any clothing from the burned area unless it is stuck firmly to the skin. In that case, cut away as much clothing as possible.

3. If the injured area is not oozing, cover the burn with a sterile gauze pad or a clean, dry cloth.

4. If the burn is oozing, cover it lightly with sterile gauze if available and immediately seek medical attention. If sterile gauze is not available, cover burns with a clean sheet or towel.

5. Do not put butter, grease, or powder on a burn. All of these so-called home remedies actually can make the injury worse. For anything more serious than a superficial burn, or if redness and pain continue for more than a few hours, consult a physician. All electrical burns and burns of the hands, mouth, or genitals should receive immediate medical attention. Chemicals that cause burns also may be absorbed through the skin and cause other symptoms. Call the Poison Help Line (1-800-222-1222) or your pediatrician after washing off all the chemicals.

If your pediatrician thinks the burn is not too serious, he or she may show you how to clean and care for it at home using medicated ointments and dressings. When treating a burn at home, watch for any increase in redness or swelling or the development of a bad odor or discharge. These can be signs of infection, which will require medical attention. See First Aid for Burns: Parent FAQs for more information

Under the following circumstances, hospitalization may be necessary:

• If the burns are third degree.

• If 10% or more of the body is burned.

• If the burn involves the face, hands, feet, or genitals, or involves a moving joint.

• If the child is very young or fussy, and therefore too difficult to treat at home.

How to Safeguard Your Family from Fires, Scalding & Burns:  

• Install smoke detectors in hallways outside bedrooms, the kitchen, living room, and near the furnace, with at least one on every floor of the house. Test them every month to be sure they work. It is best to use alarms that have long-life batteries, but if these are not available, change batteries at least annually on a specific date that you’ll remember (such as January 1 of each year). Consider investing in an alarm that allows you to record your own voice calling to your children by name; these new alarms may be more effective in rousing sleeping children than alarms with loud beeping tones.

• Practice home fire drills. Make sure every family member and others who care for your children in your home know how to leave any area of the home safely in case of a fire.

• Have several working fire extinguishers readily available and familiarize yourself with how to use them. Place fire extinguishers around the home where the risk of fire is greatest, such as in the kitchen, furnace room, and near the fireplace.

• Teach your children to crawl to the exits if there’s smoke in the room. They will avoid inhaling the smoke by staying below it.

• Purchase a safety ladder if your home has a second story, and teach your children how to use it. If you live in a high-rise building, teach your children the locations of all exits and make sure they understand never to use the elevator in a fire. It can become trapped between floors or open on a floor where the fire is burning.

• Agree on a family meeting point outside the house or apartment so you can make certain everyone has gotten out of the burning area.

• Teach your children to stop, drop, and roll on the ground if their clothing catches fire.

• Avoid smoking​ indoors.

• Do not leave food cooking on the stove unattended.

• Lock up flammable liquids in the home. It is best to store them outside the home, out of children’s reach, and away from heat or ignition sources.

• Protect your child from tap water scalds. Adjust your water heater so the hottest temperature at the faucet is no more than 120 degrees Fahrenheit (48.9 degrees Celsius) to prevent scald burns. See 5 Bathroom Safety Tips for Infants & Young Children.

• Don’t plug appliances or other electrical equipment into extension cords if they place too much “amperage” or load on the cord, thus creating a potentially unsafe situation. See Electric Shock Injuries in Children for more information.

• Keep matches and lighters away from children, locked and out of reach.

• Avoid all fireworks, even those meant for consumer use.

Additional Information:

​

The information contained on this Web site should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.

Estimating the Size of a Burn

Topic Overview

You can quickly estimate the size of a burn by using the “rule of nines.” This method divides the body’s surface area into percentages.

Estimating burn size in adults

See a picture of the “rule of nines” for adults.

• The front and back of the head and neck equal 9% of the body’s surface area.
• The front and back of each arm and hand equal 9% of the body’s surface area.
• The chest equals 9% and the stomach equals 9% of the body’s surface area.
• The upper back equals 9% and the lower back equals 9% of the body’s surface area.
• The front and back of each leg and foot equal 18% of the body’s surface area.
• The groin area equals 1% of the body’s surface area.

Estimating burn size in babies and young children

See a picture of the “rule of nines” for babies and young children.

• The front and back of the head and neck are 21% of the body’s surface area.
• The front and back of each arm and hand are 10% of the body’s surface area.
• The chest and stomach are 13% of the body’s surface area.
• The back is 13% of the body’s surface area.
• The buttocks are 5% of the body’s surface area.
• The front and back of each leg and foot are 13.5% of the body’s surface area.
• The groin area is 1% of the body’s surface area.

The “rule of palm” is another way to estimate the size of a burn. The palm of the person who is burned (not fingers or wrist area) is about 1% of the body. Use the person’s palm to measure the body surface area burned.

It can be hard to estimate the size of a burn. If you think a burn is a certain size but you are unsure, it is best to discuss the size of the burn with your doctor.

Credits

Current as of:
February 26, 2020

Author: Healthwise Staff
Medical Review:
William H. Blahd Jr. MD, FACEP – Emergency Medicine
Adam Husney MD – Family Medicine
Kathleen Romito MD – Family Medicine
H. Michael O’Connor MD – Emergency Medicine
Martin J. Gabica MD – Family Medicine

Current as of: February 26, 2020

Author:
Healthwise Staff

Medical Review:William H. Blahd Jr. MD, FACEP – Emergency Medicine & Adam Husney MD – Family Medicine & Kathleen Romito MD – Family Medicine & H. Michael O’Connor MD – Emergency Medicine & Martin J. Gabica MD – Family Medicine

How to lighten hair and not screw it up

Hair lightening is a traumatic procedure in any case, but modern technologies make it softer. It is unlikely that you will be able to get a platinum blonde the first time, but lightening your hair is not such a big problem today as it was ten years ago, for example.

At what percentage of oxide to work and how light shade you can get, the master will determine after diagnostics. Get ready to honestly talk about all the damage and chemical reactions that your hair has already suffered, and don’t hide anything from the master: if you straighten your hair every day or dye it with henna three years ago, say so.This is necessary so that the master can assess the risks and determine the sequence of work, as well as choose the appropriate formula.

“There is a misconception that it is better to lighten the hair with a low percentage of oxide, but keep the paint longer. With complex techniques, stylists admit the possibility of holding the clarifier for up to several hours instead of the recommended 50 minutes, but this adversely affects the quality of the hair. To get the best results and minimize stress on the hair, I recommend lightening the hair in several passes or choosing a higher oxide. “Natalia Sitdikova, stylist and technologist Redken

But it is best to follow the manufacturer’s recommendations. 6% is the standard percentage for natural and colored hair; 3% – for thin, damaged or previously bleached hair; 9% and 12% – only for open techniques without covering the strands in foil.

“Any, even super-sparing coloring is a chemical process. To preserve the quality of my hair, I use plexuses, in my case it is Olaplex. It helps disulfide bonds to break down less under chemical influences, but it does not affect the dyeing result – it doesn’t matter if you lighten your hair, dye it in a darker shade or wash off old paint. From my own experience, I can say that it really works. ” Elena Utrobina, stylist @authentica_club

And some dyes, on the contrary, are used only on clean hair. If the scalp is sensitive and does not react well to paint, I recommend using the Elixir Essence, Kydra. This product is applied to the scalp before coloring and relieves all the unpleasant sensations in the process.

It is better not to lighten your hair if before that you dyed with natural dyes (henna, basma) or if your hair is badly damaged.What result you will get, even Susan Miller cannot predict. If the stylist says that it is better not to touch your hair at all, do not look for a master who will agree, but just accept it. In the event that the color does not turn out the way you wanted, or the hair falls off (yes, this can also be), you can sue the master for monetary compensation, but this is so-so consolation.

“How the hair behaves during the bleaching process after dyeing with henna depends on the quality of the henna itself. Often, stylists are faced with a situation where the hair acquires a bright green-light green shade during lightening. It is no longer possible to get rid of it. The only way out is to dye it in a darker color. If during the consultation it became clear that the client was dyeing his hair with henna, the master should conduct a test on one of the strands and decide what you will do. ” Natalia Sitdikova, stylist and technologist Redken

Bleached hair itself is yellowish.A cold shade is achieved by toning with a cold pigment, which is washed out of the hair quite quickly. To keep the shade as long as possible, do not overheat your hair with stylers and a hairdryer and do not use cosmetics with a lot of oils: they wash out the pigment. We recommend purchasing special products with purple pigment: shampoos, conditioners or homemade toning balms. Many brands have these, from the most budgetary to the luxurious. Our recommendations: conditioners “Achimik”, Davines and Blonde Angel, Kevin. Murphy.

As a bonus, they asked Elena Utrobina to tell why the hair balms that are put in boxes with dyes from the supermarket are so cool.

“Their super-ingredient is just silicone (the beauty brains specifies Bis-Hydroxy / Methoxy Amodimethicone). It “covers up” all the imperfections on the hair, making it shiny and smooth, because after household dyes, the hair is usually dry and porous. But when this “miracle” is washed off, we see the hair in an even drier state than it was before.I would recommend using hair products with amino acids and herbal extracts to nourish, not just smooth. These products may not work as a daily conditioner because they weigh heavily on the hair. ”

90,000 Redness of the scalp – what does this mean? | Head & ShouldersRU

If your scalp is a little red, you may have dandruff. Find out why your scalp is irritated and why it turns red. Our tips will help you with this

Skin redness is usually a sign of irritation. When the body reacts to irritation, it can send more blood to the surface of the skin to flush out the irritant.

However, it is not so easy to understand what exactly is an irritant. Skin redness can be caused by many reasons, including:

• Dandruff

• Seborrheic dermatitis

• Sunburn

• Eczema

• Sensitive skin

Skin redness and dandruff

Dandruff is one of the most common causes of scalp redness.

It appears as a result of a reaction to the microorganism Malassezia globosa , which lives on the scalp of all people.

Half of all people in the world are susceptible to Malassezia, resulting in irritation, redness and dandruff.

Dandruff can also cause itching. When you scratch your scalp, you can damage the scalp even more, leading to increased irritation.

How to deal with redness of the skin

To get rid of skin redness, start with the root cause. In many cases, it is dandruff.

Choose a shampoo specially formulated to fight dandruff. Our anti-dandruff shampoos have only passed clinical trials to prove their effectiveness against dandruff; they also reduce scalp redness *.

Their pH balanced formulas are gentle enough for daily use to prevent dandruff by addressing the underlying cause of irritation and redness.

Try our shampoos to soothe and refresh the skin, such as the Soothing Care Shampoo to relieve itching caused by dandruff to soothe and refresh the skin.

Learn more about itchy scalp

* caused by dandruff

Answers to the most popular paint questions

COLOR SCIENCE

Hair coloring: why is the result sometimes different from the one shown on the package?

No hair is the same. Each hair has not only a unique structure, but also its own “history”, because it is imprinted by all the procedures that were performed earlier: dyeing, curling, etc. Accordingly, the color after staining may differ slightly.

Another factor that influences your perception of color may be the photograph itself on the package. We try to keep the color of the hair on the box with the paint as close as possible to that which will be obtained as a result of dyeing.

We recommend that you test the dye on an inconspicuous strand before the procedure to see what color will turn out exactly on your hair.

Paint package numbers: what do they mean?

What is the coloration level? There is an international scale of 10 color shades ranging from very light to black.

This number reflects the expected final color:

10. Very, very light blond
9. Very light blond
8. Light blond (light blond)
7. Blond (medium blond)
6. Dark blond (dark blond)
5. Light brown (light brown)
4. Brown (medium brown)
3. Dark brown (dark brown)
2. Dark brown (deep dark brown)
1. Black

Be careful: the dyeing result depends on the hair color: natural or previously dyed.

If you have never dyed your hair before, you need to determine your natural hair color. Usually the color is determined by the hair roots. Remember that people tend to perceive their hair as slightly darker than it actually is.

If you want to lighten your hair, the dye will not be enough. You will need pre-clarification with special products.

Hair coloring: why is the result sometimes different from the one presented on the package?

No hair is the same.Each hair has not only a unique structure, but also its own “history”, because it is imprinted by all the procedures that were performed earlier: dyeing, curling, etc. Accordingly, the color after staining may differ slightly.

Another factor that influences your perception of color may be the photograph itself on the package. We try to keep the color of the hair on the box with the paint as close as possible to that which will be obtained as a result of dyeing.

We recommend that you test the dye on an inconspicuous strand before the procedure to see what color will turn out exactly on your hair.

Color Correction: What Does It Mean?

If you do not like the color obtained as a result of staining, you can go through the color correction procedure.

Contact the Consumer Care Center, our consultant will advise you on what can be done to correct the resulting hair color.

IMPORTANT! BEFORE APPLICATION.

Sensitivity test: Is it necessary to perform a sensitivity test before each staining procedure?

Yes, sensitivity test must be performed every time before paint application.

Sensitivity to paint components may decrease or increase over time.

We recommend performing a skin test 48 hours before staining. Just apply a small amount of the dye to the skin behind your ear or wrist and wait.

If your skin reacts to paint: itching, redness, etc. – consult a dermatologist.

Skin Sensitivity Test: How To Do It?

1. Choose a location for the test, usually a small area (1–2 cm) behind the ear.
2. Wipe the skin with rubbing alcohol.
3. Using a cotton swab, apply a small amount of paint to cleansed skin.
4. Let the paint dry.
5. Apply paint 2 or 3 more times.
6. Close the paint container well.
7. Leave the paint on the skin for 48 hours, do not rinse.

If you notice burning or redness at the test site, do not use paint and consult a dermatologist.

I didn’t have a reaction to the paint last time: Do I need to do the sensitivity test again?

Yes, you should do a skin sensitivity test every time before dyeing your hair, even if previous tests have not shown any results.

Sensitivity to paint components may decrease or increase over time.

Garnier hair dyes are created on the basis of soft, non-aggressive ingredients, but in some people they can cause allergic reactions.

Hair dye: can I use it after dyeing with henna or compositions containing metal salts?

No, the use of Garnier dye on hair previously dyed with henna or compounds with metal salts is not recommended.Hair structure can become brittle.

We advise you to wait a while before using the dye on hair previously dyed with henna or metal salt formulations.

Garnier dyes will improve the condition of previously colored, dry hair.

Home color and permanent curling / hair straightening: can these two treatments be done on the same day?

We recommend that you first have your hair permanently curled or straightened by a professional hairdresser.Then, after two weeks, you can dye your hair at home.

During these two weeks, we recommend that you wash your hair regularly to completely remove any chemical residues.

Use Garnier care products to restore hair after permanent curling / straightening. You can choose shampoo, conditioner and hair masks that take care of your hair between curling / straightening and then colorizing.

Tattoos: are they compatible with hair coloring?

Temporary / black henna tattoos are risky in that you may become sensitive to PPD – paraphenylenediamine – a substance found in black henna. We recommend that a skin sensitivity test be performed on the skin behind the ear or on the wrist before staining, 48 hours before the expected staining time.

Recently, the number of allergic reactions associated with hair coloring has increased.In fact, these could be reactions triggered by high PPD levels. PFD can also be found in hair dyes, but in much lower amounts.
If you have an allergic reaction after getting a black henna tattoo, it can lead to a high sensitivity to FPD in the future.

Consult a dermatologist if you experience similar symptoms.

Garnier is committed to complying with the legal requirements for ingredients in cosmetic products.

Pigtails / dreadlocks / hair extensions, wigs: can they be dyed?

Pigtails:
We do not recommend dyeing pigtails, even very thin ones. This prevents the dye from being evenly distributed and penetrating deep into the hair.
Before dyeing the hair, the braids must be unraveled.

Natural Hair Extensions:
Dyeing natural hair extensions is possible (if attached with silicone or keratin), however we do not recommend this procedure as it is too complicated.
If you still decide, do a test: apply paint to a less visible part of the extended strand to evaluate the final dyeing result.
Use two sets of paint, one for the dough and the other for staining.

Artificial hair extensions:
We do not recommend dyeing synthetic hair.

Wigs:
We do not advise you to dye your wig, whether natural or synthetic.

Pregnancy and hair coloring: are they compatible?

Yes, you can dye your hair during pregnancy if you have previously used hair dyes.

We recommend performing a skin sensitivity test (on the skin behind the ear or on the wrist) 48 hours before staining. During pregnancy, the skin can become more sensitive, so we insist on having a skin test beforehand. If you notice that your skin has reacted in an undesirable way, see your doctor.

Garnier hair dyes are made on the basis of natural ingredients such as avocado oil, bamboo extract, etc. Therefore, the use of Garnier dyes is safe even during pregnancy.

Chemotherapy and hair coloring: are they compatible?

We strongly recommend that you seek the advice of your healthcare professional if you decide to use hair coloring while undergoing chemotherapy. Your doctor is the only one who can give you competent advice on the safety of this procedure.

If your doctor thinks that staining will not be harmful, we still insist on a skin sensitivity test 48 hours before staining.If during the test you develop an allergic reaction to the paint, inform your doctor and refuse to apply paint.

All Garnier products contain natural ingredients that have a beneficial effect on hair. Use Garnier dyes to achieve a natural-looking hair color.

Bleached / bleached hair: is coloring possible?

Garnier hair dyes are compatible with many cosmetics.

Contact our consultant, he will tell you if the Garnier paint you have chosen is compatible with the products that you previously used for coloring.

All Garnier colors are designed to delicately affect your hair, even if it has previously been bleached / lightened. You can choose any color or type of dye (semi-permanent or permanent) to make your hair look healthy and natural.

PAINT APPLICATION

Painting: tools required

Each pack of Garnier stains contains all the tools you need.

However, for the best results when dyeing at home, we recommend that you prepare:

1. Old or dark towel.
2. Wet wipes, to remove paint marks on the face if necessary.
3. A clock to time the exposure of the hair to the composition.
4. Scissors to open the paint pack.
5. A good book, magazine or DVD to enjoy your coloring time.

Hair wash: Is it necessary to wash the hair before dyeing?

It is not necessary to wash your hair before dyeing. Moreover, the best coloring can be achieved by applying the coloring composition to unwashed hair.The secretion of the sebaceous glands will protect the scalp and allow the color to last longer.

Ingredients: Why should the composition be applied to the hair immediately after mixing the ingredients?

The ingredients of the coloring composition are sold in different containers. As soon as they mix, a chemical reaction begins.
If you store the mixture in a closed bottle, the chemical reaction between the ink and the developer will continue.

Eventually, if the mixture is not applied to the hair, oxygen will be released. Under its influence, the container with the mixture may explode.

Always follow the directions for use printed on the Garnier paint package.

Recommended exposure time: is it important to observe it?

We cannot guarantee an excellent result if you do not follow the recommended exposure time of the hair dye.

The countdown begins from the moment the composition is applied to the hair.

The main rule for painting is to strictly follow the instructions on the Garnier paint package.This is a guarantee of the best possible result and optimal effect on the hair.

Head massage before rinsing paint: is it really necessary?

Yes, it is necessary to massage the head and hair before rinsing the paint.

Carefully follow the instructions on the Garnier paint packaging:

1. Leave the dye composition on the hair for the time specified in the instructions.
2. Moisten hair a little and massage gently for 2 minutes.
3. Rinse paint off with water until water is clear.
4. Apply the supplied final conditioner.

Massaging the scalp and hair before rinsing off helps to emulsify the dye, fix the color and add shine to the hair.

Always follow the directions for use printed on the Garnier paint package.

I have some paint left: can I use it next time?

No, you cannot store the mixture until the next stain.

If you have mixed the ingredients, you must immediately apply the composition to the hair. Mixing starts a chemical reaction between the dye and the developer.
The mixture should be applied to hair immediately after preparation.

Break off the tip of the mixing bowl and apply the formula directly to the hair. After applying, discard the remaining mixture; you will no longer need it.

Strictly follow the instructions on the packaging of Garnier paint. This is a guarantee of the best possible result and optimal effect of the dye on the hair.

I have long hair, do I need more paint?

If you have long or very thick hair, we recommend using 2 identical packs of paint (same type and shade).

If during dyeing you did not have enough dye, the hair will not dye properly, and the result may differ from the desired.

If you have any questions about dyeing long / thick hair, please contact the Garnier Customer Care Center.

TIPS AND RECOMMENDATIONS

First gray hair: what should I do?

To paint over the first gray hair, it is not necessary to resort to the same means as in the case of a lot of gray hair.

For delicate painting of the first gray hair, use semi-permanent paint of the 2nd group, which does not contain ammonia. This dye will mask gray hair, bringing it closer to your natural color. The result is natural hair color and healthy shine.
Semi-permanent paint will be washed off within 6-8 weeks, without the effect of “regrown roots”.

Garnier Semi Permanent Color contains natural ingredients such as bamboo extract to strengthen your hair. The gray hair is painted over, and the hair has retained its natural color and vibrant shine.

Refresh Color: Can I refresh my hair color between dyes?

It is very easy to freshen up the color in between stains.

Just match the semi-permanent color to your hair color. Apply it and wait 5-10 minutes.

The color will look as fresh as after a new stain. The hair will have a shiny and healthy natural look.

Use Garnier semi-permanent paints to freshen up the color between stains.

Hair coloring: when should I repeat it?

There are different rules, depending on which colorant you used:

Toning shampoo (group 1)
Repeat the staining after the 6-8th shampoo (after the first application).

Tinting (semi-permanent) paint (group 2)
Repeat the coloring 6-8 weeks after the first application – this will refresh the color and increase the shine of the hair.

Permanent paint (group 3)
Apply to regrown roots 6-8 weeks after first use.

For color groups 2 and 3: make sure you follow the guidelines for re-coloring hair as printed in the instructions for the color.

Garnier offers you all three types of color products, depending on your preferences.Choose a temporary or permanent dye – we guarantee an excellent result, rich color and care for the health of your hair.

Tinting of regrown roots: when can it be done?

We recommend waiting at least 4-6 weeks before recoating.
On average, hair grows 2 cm per month – this is the average, hair can grow faster or slower.

The best time for touch-up is when the roots really start to show.Touching up before 4-6 weeks will not be warranted, as most likely the regrown roots will not be visible yet.

When coloring hair, it is important to apply the color only to the roots and not to the entire length of the hair.

Follow the instructions for use carefully.

Permanent dyeing Garnier is a bright color for a long time and without harm to hair. The nourishing ingredients of Garnier dyes protect hair during coloring, nourish it and give it a delightful shine.

Mixing different shades: is it possible?

Mixing different shades is not recommended as it can lead to unpredictable results.
If you mix two shades, we cannot predict what color your hair will be dyed.
Remember, once you’ve opened a hair dye, you can’t leave it for later use.

If you are not sure which shade is right for you, please contact our consultant. He will be able to suggest which Garnier product is right for you.

I want to change my hair color: what do you need to know?

There are several rules that you can follow to avoid surprises and frustrations when changing hair color.

So, if you want to change your hair color, you must wait at least 3 weeks from the last dyeing. After this time, you can dye your hair again.

If you have any questions or doubts, please contact our consultant. He will answer any question and help you decide which hair coloring procedure is right for you.
Using Garnier paints and the help of a consultant will help you achieve maximum results.

I am choosing between shades: should I give preference to lighter or darker?

Remember, it’s always easier to darken blonde hair than vice versa.

Therefore, if you cannot decide on the shades, choose a light one. If the result is too light, you can easily achieve a darker color.

If you need additional advice, please contact our consultant. They will tell you which coloring agent is best for you.

Hair dyes: can lightening be achieved?

The answer depends on what hair color you have at the time of dyeing.

If you have natural hair:
Using the dye will help you lighten your hair by 2 tones.
If you additionally use a clarifier, the hair will be 6 tones lighter.
If you are in doubt about which shade to choose, we recommend a lighter shade, as it is always easier to darken blonde hair than vice versa.

If you have colored hair:
Using the dye will help you lighten your hair 2 tones.
You should find out if the product used to color your hair is compatible with the color you intend to use.

Garnier Coloring Products are available in many colors and shades, so you can find the one that’s right for you.

My natural color is much darker than the color my hair is currently dyed: can I reapply the color without using bleach?

No.In the event that your natural color is much darker, then before re-applying the paint you should use a clarifier. This will help to properly color the regrown hair roots.

If you have any questions about the procedure for dyeing dark hair in a much lighter color, please contact our consultant. He will help you choose a product and decide on the staining procedure.

I want to dye my hair dark: is it possible after lightening / bleaching?

Yes, you can dye your hair dark even after bleaching / bleaching, but it also depends on the shade you choose.

It is possible to make the hair one tone darker.
Before dyeing, ask your hairdresser for a prepigmentation procedure, which will enrich the hair with pigment. Pre-pigmentation is carried out only by professionals.

After that you can dye your hair at home using Garnier products.

We recommend choosing one shade lighter than the desired one if the difference between shades is very large.

Garnier Hair Dyes are great for transitioning from lighter to darker tones.

Home lightening: how many shades can I lighten my hair?

The answer depends on what hair color you have at the time of dyeing.

If you have natural hair:
Using the dye will help you lighten your hair by 2 tones.
If you additionally use a clarifier, the hair will be 6 tones lighter.
If you are in doubt about which shade to choose, we recommend a lighter shade, as it is always easier to darken blonde hair than vice versa.

If you have colored hair:
Using the dye will help you lighten your hair 2 tones.
You should find out if the product used to color your hair is compatible with the color you intend to use.

Garnier Coloring Products are available in many colors and shades, so you can find the one that’s right for you.

Super Blond: Can I Achieve This Shade At Home?

The result depends on the color of your hair at the time of dyeing.

Human hair:
If you have natural hair, or the previously applied semi-permanent dye has already come off (you have washed your hair at least 20 times since the application), you can significantly lighten your hair.

If you want to lighten your hair to a different shade, you will need a bleach.

Dyed Hair:
If your hair has been permed or permanently dyed, you won’t be able to lighten it significantly.

Apply clarifier prior to painting with permanent paint.
If you want to significantly lighten your hair, we recommend that you consult with your hairdresser or our consultant.

Black Hair:
You can’t go platinum blonde with home color products.

Hair color: why does it change in summer?

Like our skin, in summer, hair is exposed to the sun and, therefore, ultraviolet rays.

And just like skin, hair reacts to the sun by changing color.The sun will lighten hair slightly, especially when exposed to sea water or pool water.
This happens anyway, regardless of whether your hair is dyed.

Unfortunately, there are no special products for protecting hair from the sun, so a headdress is the only way to protect your hair.
You can take care to protect your hair from the damaging effects of sunlight. Use a moisturizing shampoo and conditioner daily, and a hair mask once a week.From Garnier’s beauty products, choose the one that suits your hair type.

90 000 In Sweden, the author of caricatures of the Prophet Muhammad Lars Vilks died in an accident – RBK

He was on the list of “the main enemies of Islam”, terrorists appointed a bounty on his head, they tried to burn down the artist’s house and shoot him.However, Vilks continued to draw and said that there is nothing more valuable than freedom of speech.

Lars Wilks

(Photo: Lehtikuva Lehtikuva / Reuters)

Swedish artist and author of caricatures of the Prophet Muhammad 75-year-old Lars Vilks died along with his bodyguard in the form of two policemen in an accident in southern Sweden. SVT reports this with reference to the police.

The artist’s car collided with a truck. Both cars caught fire and the road was blocked for several hours while they were being extinguished. The truck driver survived but suffered serious injuries.

“We cannot yet say how the accident happened. It is necessary to wait for the results of the investigation, ”said police spokesman Rikard Lundqvist.

Prophet cartoonist attacked in Copenhagen

Lars Vilks became widely known for his cartoons of the Muslim prophet Muhammad.In 2007, the artist painted a dog with the head of a prophet, the image was initially rejected by Swedish exhibitions and art galleries, and was eventually printed by the regional newspaper Nerikes Allehanda. The publication provoked outrage among Muslims in many countries of the world, Vilks began to receive threats, including murder. Recognized in Russia as a terrorist and banned organization “Al-Qaeda” included the cartoonist in the list of “the main enemies of Islam” and appointed a bounty of $ 100 thousand for his head.

90 000 What other writers, besides Gogol, destroyed their books?

On the night of February 11-12, 1852, Nikolai Gogol burned the second volume of Dead Souls.We have already talked about why the writer did this with his work in one of the issues of “The Cultural Question”. The sequel to the famous novel was not the only work that Gogol destroyed. 23 years earlier, in 1829, he published the poem “Ganz Küchelgarten” and, when critics criticized the book, bought all available copies and burned them.

Many other foreign and Russian writers also destroyed their manuscripts. Before Gogol, Alexander Pushkin did this. In the poet’s drafts and notes, many excerpts from works have been preserved, the full versions of which he burned. So, for example, Pushkin dealt with the poem “The Robbers”. He wrote to his friend Alexander Bestuzhev: “I burned Robbers – and they deserved it. One passage survived “. This excerpt was published in 1825, and the poet used his developments for the “Robbers” when he wrote the poem “The Fountain of Bakhchisarai”.

Pushkin destroyed his other works as well. In 1830 he burned the tenth chapter of the novel in verse “Eugene Onegin”. The poet feared political persecution because of what he wrote about the Decembrist uprising.However, before burning the manuscript, Pushkin encrypted it, and at the beginning of the 20th century, from his notes, researchers were able to restore three complete stanzas and fragments of fourteen others.

During Soviet times, many poets and writers destroyed their works for political reasons. They feared searches and reprisals. For example, before burning her poems and poems, Anna Akhmatova learned them by heart and read them to her friends. Then, together with them, the poetess restored the compositions from memory.

Osip Mandelstam believed that his works “could cost a head” , so he burned, hid or gave the manuscripts to friends.Friends and relatives later restored the poems from memory and from the preserved records. The poet’s wife Nadezhda recalled: “We had to restore them (poems. – Ed.), Because after the shocks (search, arrest, exile, illness), a lot fell out of our memory. The rescued manuscripts … during the search lay in a saucepan in the kitchen and in gray shoes ”.

Mikhail Bulgakov burned his manuscripts not only for fear of arrest and searches. Often the writer was dissatisfied with ready-made stories, translations, poems and even novels.In 1930, he burned the first version of The Master and Margarita. True, then the book had a different title. Bulgakov wanted to call her “Black Magician” or “Juggler with a Hoof,” and make Woland the main character. Researchers believe that the writer did not plan to burn the novel, but did it in their hearts on the day when the censorship banned his play “Cabal of the Holy”. Bulgakov himself recalled: “ A demon has possessed me … <...> I began to smudge page after page of that novel, which was destroyed three years ago.What for? Do not know. I am amuse myself! Let it fall into oblivion! “

Foreign authors also destroyed their manuscripts. For example, the English poet and artist Dante Gabriel Rossetti put a notebook with unpublished poems in the coffin of his wife Elizabeth Siddal and vowed not to study literature anymore. However, seven years later, Rossetti decided to print works from that manuscript, and at the poet’s request, the grave of his wife was opened. Rosseti restored and published the poems, but later regretted it.He called his act “ an outburst of literary ambition “.

And Robert Louis Stevenson burned the first manuscript of The Strange Story of Dr. Jekyll and Mr. Hyde after criticizing his wife. Frances Stevenson read all of her husband’s works and left her comments and notes in the margins of the drafts. Stevenson got acquainted with the marks of his wife, burned the work and the same day began to write it again. He completed the second version of The Strange Story of Dr. Jekyll and Mr. Hyde in three days.

The writer Franz Kafka is believed to have destroyed 90% of his manuscripts.During his lifetime, he published only a few stories, which received negative reviews from critics. After that, Kafka burned almost all of his works. Shortly before his death, he gave the remaining manuscripts to his friend Max Brod and asked to deal with them too. However, Brod read the writer’s drafts and published them. That is why Kafka’s novels “The Trial”, “The Castle” and “America” ​​are known today.

Sergei Bigel, who escaped from Belarus to Lithuania: they beat me, they wanted to burn the hair on my head

– Sergei, what would you say to those Russians, Poles and Lithuanians who believe that Lukashenka is an excellent president, cares about Belarus and its inhabitants, and life in your homeland is much better than life in Lithuania?

– For those Lithuanians who believe that we have risen there for nothing and are trying to destroy our country, I propose to change places: let me live in your place in Lithuania, and you in mine in Belarus.I think that no later than in a year you will be running away from Belarus without pants, just to run here faster, so as not to stay there. This I guarantee you one hundred percent.

– When did you begin to understand that something was wrong with Lukashenka and his management methods?

– When you go to Lithuania, Poland, you see how people can live in a normal country, and you just understand that we, Belarusians, stepped somewhere in the wrong place at one time, and therefore that choice, that mistake must be corrected.For this reason, you go to a rally and think: we will win, everything will be fine, at least my children will live well in this country.

– Did you take part in the protests from the very beginning?

– Until August 12, when I was not seized, beaten and because of this I was not taken to the hospital, until that moment I was, say, such a couch “protest”. I could be indignant on the Internet, talk to someone on the street about this, but in such a way as to specifically go to rallies and speak … On that day (when we were detained) we did not go to the rally.We just went to file a paper against what began to happen, that they began to kill people, we made an appeal to our authorities, to the local authorities and went – me, my brother and my two friends – to bring him to the village council.

– Did the police detain you?

– We were detained by riot police. When we gathered in one place and moved there (to the village council) to bring this appeal, a bus drove up, six or seven riot policemen in masks with all the ammunition jumped out. We immediately lay down on the ground without their help, because I had already heard a lot about what they were doing.They started beating me already there, near the car, then in the car on the way to the police department (district department of internal affairs). In short, after meeting them, I became an ardent “protest”. Before that, I perceived … Well, people say that they beat someone until I hit it myself – I did not believe … Let’s just say, I thought that the information was exaggerated. Maybe he believed that someone somewhere got a little, but until you yourself get into this situation, until you feel on yourself what criminal power is … When you are lying such a healthy, respectable man, you are law-abiding citizen, and right in the militia, on the territory of the police department, the body that is supposed to protect people, they put your face in the ground, knead you with these clubs, for example, they jump on you and you lie … The head even at that moment cannot accept that this is happening it is with you that it can be so at all.

– What happened to you and your friends next?

– The four of us were lying between these two seats, they pushed us there, pressed in, everyone rode on us. Only one riot policeman was driving, and everyone else sat on us, just climbed on us. It turns out that I still got in that way … Sasha Grimaytya was loaded first, then Vitalik, then Vitya and me. When they loaded the very last one, my legs were sticking out, I probably couldn’t fit. And he (the riot policeman) began to beat the doors on my feet and yelling: “Take it away.”I hum to him, because I can’t say anything, there’s a man sitting right on my head, I don’t have a place, he somehow incredibly twisted his legs, tied him almost in a knot, the doors closed, and we drove off.

– Did they continue to beat you in the car?

– And it was in the car … Okay, I, the two of them were sitting on me and it might have been uncomfortable for them to beat me, but even then … one took it and started rubbing the hair on my head with his knuckles like this, shaggy, and the other says : “set it on, set it on”.I don’t see it, but I feel it, I hear it click, I think, damn it, this is a lighter, my hair is about to burn. With some incredible effort I freed my hand, because they are behind me, I stick it out to cover my head, and he takes my finger and twists it with all his might, then tore my nail and said: “animal, why are you closing “. Well, how I will not close, he wants to set my hair on fire!

And, for example, Sasha Grimayt, he was beaten so that the sounds were already squelching: take a piece of raw meat and hit it with your fist, there is already something like this … and they beat him with even more cruelty.The riot police beat him more than anyone else, then two policemen pulled him for an interrogation at the police station. Sasha could hardly move his legs, they stretched. Sasha says: “don’t hit me guys, I’m already sick.”

– Did they continue to beat you?

– People, our volunteers, were on duty at the entrance to the RUVD … When we stopped in the courtyard of the RUVD, riot policemen told us that if we peep once and the people standing there hear us, they will take us to the forest and more than us nobody will find it. The riot policeman pulled me out by my legs, I immediately fell down, said “hands behind my head”, and then changed my mind and said: “hands behind my back.”A little later, the riot policeman simply dragged me by the legs and put there, probably, two people where he needed, well, as I understand from the blows, at that time they beat me and the other guys with clubs.

– Were you scared?

– It hurts, scary, offensive, and you ask this, you say: “Everything, everything I lie, I do not resist.” And then on their part – a bunch of swearing, insults, beatings. So they put us all on the asphalt, they told us to lie down and just look at the ground. Well, how long will you lie like that with your hands behind your back.Firstly, hands tremble from tension, when you lie like this, you tremble, because this is an unnatural posture for a person. You can’t look down all the time, I had my glasses in my hand, then, when I fell, I managed to put them on, but that was unnecessary. I was lying, my neck was numb, and I put my head on one side to make it easier. The riot policeman approached: “Turn your head, I said.”

I turned my head back, buried my nose in the ground, then it seemed to me that they had gone to smoke or something … I couldn’t see from below, my neck became numb again, and I turned my head a little bit in the other direction, and the riot policeman, apparently, he stood waiting, came up, stepped on my face: “I told you to turn your head.”At the same time, he crushed his glasses. When they cracked, maybe he thought my skull cracked, and then he stands like this and says: “Sorry about the glasses.”

© Itar-Tass / Scanpix

– What did the police chief do?

– Well, we were lying for a while, then some people left the police department, asked questions, shouted: “Why did they organize the meeting.” But as soon as you start saying that we did not organize the rally, but brought an appeal to the authorities, a hail of blows pour in.You are not allowed to say anything, for every word there is a hail of blows. Then the head of the police department came out and said: “Now I will ask questions, if one of you forces me to repeat the question twice, you will feel what the threat is.” And the very first question to Vitalik … We are all lying face down, you do not know who he is addressing, because he is standing behind, and Vitalik says: “You are for me?” And they immediately began to beat him. The head of the police later realized that it was necessary to at least somehow give the name, to whom you are now addressing, since people are lying on the ground with their backs to you.

Then I ended up in the hospital, ran away from the hospital, because they told me that as soon as I got better, they would take me back to the police cell. They didn’t even want to give me away from the cell, my face was covered in blood, my eyebrow was cut, my head was spinning, I had a concussion. I thought that my ribs were broken, and for a month after that it was difficult for me to breathe. It turned out that when they jumped on me, they stretched the intercostal ligaments.

– How do you assess what happened to you?

– This is the biggest humiliation in my entire life.Most, because up to this moment there were some troubles, problems, arguments with someone – this is nothing compared to the fact that you were trampled on as a person, as a person. You feel no better than some kind of cattle on the same collective farm who is prodded with an electric shock: where to go, where to graze and what to do. You really associate yourself with someone who is far from a person. Life in the 21st century in the center of Europe, where every day, just in case, a person carries a prison bag with him in his bag. Hello North Korea!

– When and why did you decide to flee Belarus?

– After escaping from the hospital, I began to go to all rallies in a row, at one of them riot policemen ran up to us and began to bludgeon everyone in a row.I had our Belarusian flag on a stick in my hands, and when a group of masked people began to beat us up, I just began to fight back, which in Belarus lasts about eight years. Therefore, I made the decision to flee to Lithuania with lightning speed and the next day I was already here. Four hours later, on the same day as I crossed the border, doors were broken into my house, where I am registered, in the village. It seems that half of the army came to grab me, such a big and dangerous bandit. And the policemen, and some officers of the bodies in civilian clothes.

– Did you cross the border with Lithuania without hindrance?

– At that time, apparently, I had not yet been added to the suspect database, so yes, I calmly arrived in Vilnius by bus.

– Did your wife support your decision to flee to Lithuania?

– My wife, of course, supported my decision to leave, because she said that it was better for me to be free than in prison. And it is not known how all this will end in prison, so she definitely reacted well.

– Once in Lithuania, did you feel safe?

– There were messages from the so-called “one-day” accounts on Facebook or VKontakte, sms came to the phone, the meaning is: “We will get you in Lithuania and go home in the trunk.” I think that this is impossible, because both justice and the law work in Lithuania, but it is still morally crushing.

– Did the consequences of the arrest and beatings pass without a trace for you?

– I went through customs in Norway by car, and they have an inspection procedure, I just got into it.One of the stages of the search is when you are brought into a separate room, the so-called waiting room, there is only one bench in it, embedded in the wall, that is, it is very similar to the so-called “glass” in which I was sitting in the police department when I went there placed. I spent almost a month in Lithuania, Norway and Sweden, but when I was locked up in a cell, I experienced such a psychological shock … I thought that I had already forgotten everything that was, and there is no psychological trauma, but when I sat down and thought about how everything looks like … I am sitting almost like in a cell of the police department, I started to panic that the doors will open now, these masked men with truncheons will burst in and start beating me.Then I wrote a complaint to the customs that it was not necessary with people: kick me out into the street, give me any other room where there will be a TV, coffee and everything else, just don’t keep me in such a waiting room. I left this waiting room and my hands were shaking, so I cannot say that all these beatings and tortures passed without a trace for me.

– What emotions and feelings do people in police uniform evoke in you after fleeing to Lithuania?

– After my arrival, I was afraid of your police for another week from old memory.I tried to bypass, so God forbid not to meet with them. Moreover, the police are nowhere to be seen, the police appear only where they are needed. Not like ours, when the police walk the streets and they need the fear of people so that everyone can see – we are here, we are here! For example, once, already in Panevezys, I met the policemen at the exit and I had a click – damn it, turn somewhere, what to do so as not to meet with them. The instinct of self-preservation worked, but then I calmed down, everything was a little forgotten.Now I look at everything and understand that the law enforcement agencies can be different, not the same as they paint us in Belarus. There may be much fewer police officers, and they will cope with their work, they will not beat people.

Text prepared with the support of the Pulitzer Crisis Reporting Center.

90,000 Kadyrov promised to burn the brigadier general of Ichkeria: Politics: Russia: Lenta.ru

Head of Chechnya Ramzan Kadyrov threatened with reprisals Akhmed Zakayev, a former emissary of the Chechen separatists who received political asylum in Great Britain.He stated this during a joint live broadcast on Instagram with the speaker of the parliament of the republic Magomed Daudov. A translation of their conversation from Chechen is quoted by “Kavkaz. Realii “( is included by the Ministry of Justice in the register of organizations performing the functions of a foreign agent ).

“If you say my father’s name again, you’ll see what happens to you. Even if this world burns with a blue flame, I will burn you in a blue flame if you mention the name of my father, ”Kadyrov promised.

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The head of Chechnya also called Zakayev a chicken and said that he had never had his own opinion.According to Kadyrov, the former brigadier general of the self-proclaimed Chechen Republic of Ichkeria (CRI) did not keep his promise to return to Chechnya with his comrades. The head of the region believes that his critics are seeking threats similar to those that he expressed in order to obtain political asylum in different countries on the basis of these statements. “We will not kill you, we need you alive, healthy. We will bring you home and bring you to your knees in front of people. Don’t die yet, beware of the coronavirus there, goats, “Kadyrov added.

He also stated that the former President of the CRI Aslan Maskhadov considered Zakayev a “traitor and a complete deserter” who had no right to return to the republic.