Background: Composite reconstruction with a dermal substitute followed by skin graft is sometimes used for reconstructing high-quality skin while preserving donor sites. This often necessitates 2 separate procedures, additional general anesthetic, and longer hospitalization. Concurrent use of dermal substitutes and skin graft in a single stage has been previously reported in small series. Here, we report our experience with single-stage skin reconstruction with Integra and split-thickness skin graft for coverage of wounds post burn eschar excision and post burn scar contracture release. Methods: This is a retrospective review of consecutive operations from 2013 to 2017 in which single-stage bilayer reconstruction (SSBR) was performed. Data were obtained from electronic medical records and perioperative photographs. Results: In this 5-year period, 13 surgical sites were identified in which SSBR was used in 8 subjects. Average and median graft take was 86.2% and 95%, respectively. Graft take was over 90% in 10 out of 13 cases. One case required regrafting after initial graft failure. Conclusions: In the appropriate setting, SSBR is a practical technique in covering wounds post burn eschar excision and post burn scar contracture release resulting in reasonable graft take. Use of noncontaminated wound beds is crucial. Although there is risk of regrafting, it is not clear whether this risk is any higher than in split-thickness skin grafting alone. This study was unable to evaluate contribution of dermal substitute to contraction, function, and mobility, nor how hypothesized improvement of skin quality compares to the original thick dermal substitute. We recommend further investigation.

Background: Cranioplasty for acquired cranial defects can be complex and challenging. Benefits include improved cosmesis, protection of intracranial structures, and restoration of neurocognitive function. These defects can be reconstructed with preserved craniectomy bone flaps, split autografts, or alloplastic materials. When alloplastic cranioplasty is planned, the material should be carefully selected. There is confusion on which material should be used in certain scenarios, particularly in composite defects. Methods: The PubMed database was used to conduct a nonsystematic review of literature related to these materials and the following factors: time required in preoperative planning and fabrication, intraoperative time, feasibility of intraoperative modification, fixation method (direct or indirect), implant cost, overall complication rate, and surgical revision rates. Results: Surgical revision rates for alloplastic materials range from 10% to 23%. Retention of titanium mesh at 4 years is 85% in composite reconstruction with free fasciocutaneous and free myocutaneous flaps. In composite reconstruction with locoregional and free muscle flaps, the retention of titanium mesh at 4 years is 47%. The retention of nontitanium and nonpreserved autogenous reconstruction is 72% and 82%, respectively. Conclusions: Alloplastic materials should be considered for reconstruction of large (>100 cm2) cranial defects, especially for adult patients younger than 30 years, and all patients with bone flaps that are fragmented or have been cryopreserved for an extended period. Preformed titanium mesh provides a favorable primary reconstructive option when a staged reconstruction is not possible or indicated but should be avoided in composite defects reconstructed with locoregional scalp and free muscle flaps.

Introduction The incidence and severity of public mass shootings, and mass casualty incidents (MCI), continues to rise. Understanding the wounding pattern and incidence of potentially preventable death after these incidents is key not only to Health System and Trauma Center emergency response planning but also to community outreach and initial emergency interventions. Methods A retrospective study of autopsy reports after events with at least 10 fatalities exclusive of the assailants identified via the Federal Bureau of Investigation database from 1 January 1999 to 31 December 2020 was performed. Sites of injury, identification of weaponry, and identification of potentially survivable wounds were compiled. Results Nine events including 203 victims were reviewed. Overall, 56% of gunshots were to the head/neck/face; 37% were to the chest; 43% were to the abdomen/torso/back; 31% were to the lower extremity; and 36% were to the upper extremity. On average, there were 29 fatalities per event. Conclusion Emergency response disaster care strategy should focus on immediate point of care at the site of wounding by both the civilian population and medical personnel, as well as rapid extrication of victims for definitive medical care. Review of these autopsy results indicates exsanguination, often treatable, is the primary cause of death—supporting community education efforts in hemorrhage control. The location of the wounding patterns seen in this study warrants primary integration of craniomaxillofacial, orthopedic trauma, neurotrauma, and surgical critical care/trauma surgical specialists into the initial response team for MCI.

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