Use of Fish Skin Graft in Management of Combat Injuries Following Military Drone Assaults in Field-Like Hospital Conditions

INTRODUCTION: The 2020 Nagorno-Karabakh war was an armed conflict between Azerbaijan and Armenia over an ethnically and historically significant region. This manuscript is a report on the forward deployment of acellular fish skin graft (FSG) from Kerecis™, a biologic, acellular matrix derived from the skin of wild-caught Atlantic cod that contains intact epidermis and dermis layers. The usual intention of treatment under adverse circumstances is to temporize wounds until better treatment can be attained, although ideally, rapid coverage and treatment are necessary to prevent long-term complications and loss of life and limb. An austere environment, such as the one experienced during the conflict described here, presents considerable logistical barriers for the treatment of wounded soldiers. MATERIALS AND METHODS: Dr H. Kjartansson from Iceland and Dr S. Jeffery from the United Kingdom traveled to Yerevan, near the heart of the conflict, to deliver and train on using FSG in wound management. The primary goal was to use FSG in patients where stabilization and improvement in the wound bed were needed before skin grafting. Other goals were to improve healing time, achieve earlier skin grafting, and have better cosmetic outcomes upon healing. RESULTS: Over the course of two trips, several patients were managed with fish skin. Injuries included large-area full-thickness burn and blast injuries. Management with FSG induced wound granulation several days sooner in all cases, and even weeks in some instances, allowing a stepdown in the reconstruction ladder with earlier skin grafting procedures and a reduction in requirement of flap surgery. CONCLUSIONS: This manuscript describes a successful first instance of forward deployment of FSGs to an austere environment. FSG, in this military context, has shown great portability, with easy transfer of knowledge. More importantly, management with fish skin has shown faster granulation rates in burn wounds for skin grafting, resulting in improved patient outcomes with no documented infections.