Morphopathologic observations on high-velocity steel bullet wounds at various intervals after wounding

Management of High-energy Avulsive Ballistic Facial Injury: A Review of the Literature and Algorithmic Approach

Background:

High-energy avulsive ballistic facial injuries pose one of the most significant reconstructive challenges. We conducted a systematic review of the literature to evaluate management trends and outcomes for the treatment of devastating ballistic facial trauma. Furthermore, we describe the senior author’s early and definitive staged reconstructive approach to these challenging patients.

Methods:

A Medline search was conducted to include studies that described timing of treatment, interventions, complications, and/or aesthetic outcomes.

Results:

Initial query revealed 41 articles, of which 17 articles met inclusion criteria. A single comparative study revealed that early versus delayed management resulted in a decreased incidence of soft-tissue contracture, required fewer total procedures, and resulted in shorter hospitalizations (level 3 evidence). Seven of the 9 studies (78%) that advocated delayed reconstruction were from the Middle East, whereas 5 of the 6 studies (83%) advocating immediate or early definitive reconstruction were from the United States. No study compared debridement timing directly in a head-to-head fashion, nor described flap selection based on defect characteristics.

Conclusions:

Existing literature suggests that early and aggressive intervention improves outcomes following avulsive ballistic injuries. Further comparative studies are needed; however, although evidence is limited, the senior author presents a 3-stage reconstructive algorithm advocating early and definitive reconstruction with aesthetic free tissue transfer in an attempt to optimize reconstructive outcomes of these complex injuries.

Wound ballistics of firearm-related injuries--part 1: missile characteristics and mechanisms of soft tissue wounding

Firearm-related injuries are caused by a wide variety of weapons and projectiles. The kinetic energy of the penetrating projectile defines its ability to disrupt and displace tissue, whereas the actual tissue damage is determined by the mode of energy release during the projectile-tissue interaction and the particular characteristics of the tissues and organs involved. Certain projectile factors, namely shape, construction, and stability, greatly influence the rate of energy transfer to the tissues along the wound track. Two zones of tissue damage can be identified, the permanent cavity created by the passage of the bullet and a potential area of contused tissue surrounding it, produced mainly by temporary cavitation which is a manifestation of effective high-energy transfer to tissue. Due to the complex nature of these injuries, wound assessment and the type and extent of treatment required should be based on an understanding of the various mechanisms contributing to tissue damage.

Adult burn patients with more than 60% TBSA involved-Meek and other techniques to overcome restricted skin harvest availability--the Viennese Concept

Despite the fact that early excision and grafting has significantly improved outcome over the last decades, the management of severely burned adult patients with >/=60% total body surface area (% TBSA) burned still represents a challenging task for burn care specialists all over the world. In this article, we present our current treatment concept for this entity of severely burned patients and analyze its effect in a comparative cohort study. Surgical strategy comprised the use of split-thickness skin grafts (Meek, mesh) for permanent coverage, fluidized microsphere bead-beds for wound conditioning, temporary coverage (polyurethane sheets, Epigard; nanocrystalline silver dressings, Acticoat; synthetic copolymer sheets based on lactic acid, Suprathel; acellular bovine derived collagen matrices, Matriderm; allogeneic cultured keratinocyte sheets; and allogeneic split-thickness skin grafts), and negative-pressure wound therapy (vacuum-assisted closure). The autologous split-thickness skin graft expansion using the Meek technique for full-thickness burns and the delayed approach for treating dorsal burn wounds is discussed in detail. To demonstrate differences before and after the introduction of the Meek technique, we have compared patients of 2007 with >/=60% TBSA (n = 10) to those in a matched observation period (n = 7). In the first part of the comparative analysis, all patients of the two samples were analyzed with regard to age, abbreviated burn severity index, Baux, different entities of % TBSA, and survival. In the second step, only the survivors of both years were separated in two groups as follows: patients receiving skin grafts, using the Meek technique (n = 6), were compared with those without Meek grafting (n = 4). When comparing the severely burned patients of 2007 with a cohort of 2006, there were no differences for age (2007: 46.4 +/- 13.4 vs. 2006: 39.1 +/- 14.8 years), abbreviated burn severity index score (2007: 12.2 +/- 1.0 vs. 2006: 12.1 +/- 1.2) or % TBSA (2007: 72.1 +/- 11.7 vs. 2006: 69.3 +/- 8.7% TBSA). In these two rather small groups of severely burned patients with >/=60% TBSA, the overall survival rate of patients was 70.0% (7/10) in 2007 and 42.9% (3/7) in 2006, respectively. Almost all nonsurvivors in both years died within the first 5 days after admission. If assessing the different treatment modalities of the survivors, we found that although the Meek group patients were older (Meek 48.8 +/- 13.3 vs. non-Meek 26.8 +/- 11.5 years, P = .0381) and had consequently higher Baux scores (Meek 124.0 +/- 2.9 vs. non-Meek 93.8 +/- 8.5, P = .0095) than the non-Meek patients, this seemed to have no effect on length-of-stay (80.5 +/- 9.7 vs. non-Meek 79.8 +/- 33.0 days), hospital length-of-stay (85.7 +/- 14.8 vs. non-meek 84.3 +/- 26.1 days) or number of operations (6.5 +/- 1.0 vs. non-Meek 7.0 +/- 4.1 operations). The achieved results represent a combination of various treatment changes and, therefore, cannot be attributed to a single modality. The Meek technique is one of the technical options to choose from, to achieve permanent skin replacement; we think that it has its place if integrated in a whole treatment concept for management of severely burned patients.

[Innovative wound therapy and skin substitutes for burns]

The success of modern burn therapy is based mainly on special burn intensive care, topical treatment, early eschar excision, and wound closure by immediate skin grafting or skin substitutes. This paper describes the current state of wound care and skin substitutes in burn therapy.

[Early surgical management of severe burns]

The success of modern burn therapy is based on an understanding of the pathophysiology and application of burn intensive care implying fluid resuscitation and management of pulmonary or other organ failure. With the development of early eschar excision and wound closure by immediate grafting, survival and cosmetic outcome were further improved. Especially in post-acute therapy, early physical rehabilitation, early reintegration, and early plastic surgical correction of the sequelae are indispensable for the outcome.

Clinical Application of Microskin Grafting to Repair Granulation or Decrustation Wounds

One hundred seven granulating or decrustation wounds in 58 patients were grafted with microskin grafts of different sizes. The modified procedure has been used successfully for different wound sites, such as limb, chest, abdomen, and the back, with satisfactory results. Signs of epithelialization were shown within 5 to 22 days in 40 patients. The wound healing rate was 94.4%, including 71.9% total healing rate and 22.4% improved healing rate. We think that this method could be applied to either granulation or decrustation wounds in addition to excision wounds.

CTLA4Ig introduced by adenovirus vector locally to prolong the survival of xenogeneic skin grafts on rat burn wounds

BACKGROUND

The purpose of this study was to explore an applicable approach for prolonging the survival of heterogenetic skin grafts on burn wounds with CTLA4Ig.

METHODS

An adenovirus vector named Ad-CTLA4Ig, which could express human CTLA4Ig fusion protein, was constructed. Infecting and replicating in 293 cells, more Ad-CTLA4Ig and recombinant human CTLA4Ig (rhCTLA4Ig) were prepared, respectively. In a rat flame thermal injury model, the effect of rhCTLA4Ig on survival time of human skin graft on the eschar-excised rat burn wound was observed. Meanwhile, the efficiency of Ad-CTLA4Ig infecting cultured skin fibroblasts, keratinocytes, and partial-thickness skin samples were checked by CTLA4Ig expression essay. Then, the Ad-CTLA4Ig was administered locally on the eschar-excised wound and dermis of the skin graft, and the survival time of the human skin graft on burn wound was measured. The influence of the systemic immune function by rhCTLA4Ig and Ad-CTLA4Ig were also determined.

RESULTS

The prepared rhCTLA4Ig from the supernatant of Ad-CTLA4Ig-infected 293 cells was verified by sodium dodecyl sulfate polyacrylamide gel electrophoresis sodium dodecyl sulfate poly-acrylamide gel electrophoresis and Western blot. It was found that CTLA4Ig could significantly prolong the xenogeneic skin graft survival in a dosage-dependent manner. Interestingly, the survival time was longer when CTLA4Ig was used 24 hours posttransplantation than that at hour 0. The expression of CTLA4Ig could be observed in the cultured skin fibroblasts, keratinocytes, and skin pieces soon after Ad-CTLA4Ig transfection, as demonstrated by either immunocellular chemistry or immunohistochemistry assay. When Ad-CTLA4Ig was locally administered during skin transplantation on burn wound, the survival time was increased from 7.9 days of control group to 21.6 days, whereas the systemic immune function was not affected.

CONCLUSION

Administration of Ad-CTLA4Ig locally could prolong the survival time of xenogeneic skin graft on burn wound without significantly influencing the systemic immune function.

Ballistics for physicians: myths about wound ballistics and gunshot injuries

PURPOSE

Wound ballistics is a difficult subject. The behavior of all bullets is unpredictable but the specific effect of high velocity projectiles has been a particular source of confusion in the literature. This confusion has resulted in the likely incorrect conclusion that all high velocity wounds require massive débridement. We reviewed the entirety of the literature on this subject and concluded that high velocity weapons do not reliably create massive wounds, and judicious débridement and staged explorations may be the best treatment method for these patients.

MATERIALS AND METHODS

A MEDLINE search and retrieval were done of all pertinent references from 1966 to May 2003 concerning the field of wound ballistics. Articles initially missed in this search were obtained from the bibliography of retrieved studies. More than 70 articles and book chapters were reviewed.

RESULTS

Five common myths about the tissue effects of gunshot wounds were reviewed as well as the data that dispel these myths. Information on the effects of different bullet types, and the intended and actual effect of military rifle wounds were assessed.

CONCLUSIONS

For the majority of high velocity gunshot wounds, especially military rifles that generally fire a projectile that is meant to stay intact after impact, wound severity can be limited, even much less than that from a civilian rifle, shotgun or handgun. Judicious use of débridement during surgical exploration limits the extent of iatrogenic injury in the surgical care of these patients.