Craniomaxillofacial trauma management in austere and war zone environments - A role for composite tissue allotransplantation?

Facial composite tissue allotransplantation (CTA) is a powerful reconstructive option in cases of extensive severe facial injury and tissue loss. Despite the risk of allograft rejection and the post-operative need for lifelong immunosuppression, facial CTA can be used to restore the normal structural appearance and function of the face. Areas of socioeconomic deprivation and armed conflict zones have a high preponderance of patients with facial burns and other severe injuries. However, these regions often also suffer from lack of resources, expert surgical care and limited facilities. The purpose of this manuscript is to provide a comprehensive review of key principles relevant to facial CTA and their potential applicability in such austere environments. We present a concise literature review of the surgical and immunological basis of facial CTA aimed at the plastic surgery readership, as well as issues surrounding organ transplantations in low- and middle- income countries. We then consider the particular challenges posed by austere settings and countries of active armed conflict and discuss how these may impact the suitability of facial CTA for treating severe facial injuries in these circumstances. Facial CTA is recognised as giving huge benefits for patients with severe facial defects with potentially superior results compared with conventional autograft techniques. Its performance in austere settings is limited by scarce resources and increased pre-, intra- and post- operative risks. However, a case can be made for its use even in these more challenging situations when general organ transplantation compliance and expertise input have been addressed.

L'allotransplantation faciale de tissu composite (ATTC) est une stratégie efficace de reconstruction des pertes de substance faciales étendue. Malgré la nécessité d'un traitement immunosuppresseur ad vitam aeternam, elle peut être utilisée pour restaurer une face fonctionnelle d'apparence normale. Les atteintes faciales graves par brûlure et/ou traumatisme sont fréquentes dans les zones défavorisées et de conflit armés. En outre, les moyens humains, structurels et financiers y sont limités. Cet article a pour but de présenter une revue des bases chirurgicales et immunologique de l'ATTC et de son application par les plasticiens dans des zones faiblement développées ou en conflit. L'efficacité de l'ACT en reconstruction faciale semble supérieure aux techniques de greffes classiques. Toutefois, les risques pré-, per- et post- opératoires sont augmentés en zone hostile. Elle semble toutefois utilisable si les nécessités inhérentes au suivi d'une allogreffe sont couvertes.

Formulation and evaluation of novel mucoadhesive ketorolac tromethamine liquid suppository

Ketorolac tromethamine (KT) loaded mucoadhesive liquid suppository was prepared as a site-specific mucoadhesive rectal dosage form. Poloxamer mixture formed of 21P407 and 9P188 were used as liquid suppository base. In-vitro release rate of KT from liquid suppository was studied and compared to that from conventional suppository. The safety of the prepared suppository on GIT was conducted; hepatotoxicity of KT after 5 days of administration of liquid suppository was evaluated histologically and biochemically. The levels of liver enzymes alanine aminotransferase (ALT); aspartate amino transferase (AST); alkaline phosphatase (ALP) and lactate dehydrogenase (LDH) were used as the biochemical markers of liver damage. The results obtained revealed that the addition of KT increased the gelation temperature of poloxamer gel and reduced the gel strength and the mucoadhesive force. The study of the release rate of KT from liquid suppository was significantly higher than from conventional suppositories. Histological pictures of the GI tissues indicated no pathological damage after 5 days of rectal administration compared to oral administration. Also; it was revealed that no hepato-cellular damage occurred after administration of liquid suppository; unlike oral administration; which produced certain hepato-toxicity. The administration of KT liquid suppository did not significantly increase the basic levels of ALT and AST when compared to the control. On the other hand; the administration of KT oral solution in a dose of 10 mg/kg body weight/day for 5 days significantly increased serum ALT and AST levels; thus; KT liquid suppository in poloxamer gel was a convenient; safe and effective rectal dosage form for administration with lower hepato-toxic effect