SPECIAL TOPIC Suicide Bombing Injuries: The Jerusalem Experience of Exceptional Tissue Damage Posing a New Challenge for the Reconstructive Surgeon Dean D. Ad-El, M.D. Arie Eldad, M.D. Yoav Mintz, M.D. Yacov Berlatzky, M.D. Amir Elami, M.D. Avraham I. Rivkind M.D. Gideon Almogy, M.D. Tomer Tzur, M.D. Tel Aviv and Jerusalem, Israel Background: Suicide bomb injuries vary in form and magnitude. From the onset of the second Palestinian “intifada” in October of 2000 until January of 2004, 577 victims of suicide bombings were admitted to the Hadassah-Hebrew University Medical Center. A single bomber carrying a handbag or belt con- taining multiple metal objects and explosives carried out most of the attacks. As a result, many of the victims suffered massive tissue destruction in addition to conventional blast injuries. Methods: This article describes the management of this trauma-related “syn- drome” of combined primary and high-magnitude secondary blast injury. Results: The management of the extensive soft-tissue damage is described and two representative cases presented. Conclusion: Suicide bombing–related injuries in their present form are a true challenge for the reconstructive surgeon. (Plast. Reconstr. Surg. 118: 383, 2006.) T he trauma induced by suicide bombs is very heterogeneous, depending on the scope and target of the bombing, the type of bomb used, and the site of action. Therefore, the injuries induced by the September 11, 2001, at- tack in New York cannot be compared with those caused by Kamikaze pilots in the Second World War or to the Palestinian terror attacks on Israeli civilians. Between 1994 and 1996, 12 suicide bomb at- tacks occurred in Israel, killing 144 people and injuring 616. 1 Six of those attacks occurred on buses or in closed environments, leading to a high fatality rate (16 to 40 percent). Most of the injuries in the survivors were characterized by a combination of blast injuries and severe burns accompanied by inhalation injuries. 2 Since the onset of the second Palestinian uprising (“al- Aqsa intifada”) in Israel in October of 2000, suicide bombers have carried out multiple at- tacks on civilians. Unlike the earlier ones, many of the attacks during the second intifada took place in malls, outdoor restaurants, or other open areas. The suicide bombers used mainly handbags and belts in which metal bolts, screws, nails, and other debris were added to the explo- sive material to increase the severity of the im- pact (Fig. 1). The resultant injuries were charac- terized by exceptional soft-tissue destruction in addition to the conventional blast injuries. This outcome may be best described as a new trauma- related “syndrome” consisting of a combination of primary and secondary blast injury of extraor- dinary magnitude. From October of 2000 to January of 2004, 577 suicide-bombing victims were admitted to the Hadassah University Hospital at Ein Kerem, the Level I trauma center in the Jerusalem area. All had suffered multiple trauma of varying severity; one-third had an Injury Severity Score of 16 or more. Of the total number of patients, 137 (23 percent) had mainly soft-tissue injuries (among them, 56 burns) and were treated primarily by the Department of Plastic Surgery with skin grafting, de ´bridement sessions, removal of for- eign bodies and hand injury–related reconstruc- tive procedures (Table 1). Collaborative patients were evaluated daily by the plastic surgery and From the Department of Plastic Surgery and Burn Unit, Rabin Medical Center, Petach Tikva and Sackler Faculty of Medicine, Tel Aviv University, and the Departments of Plas- tic Surgery and Burn Unit, Vascular Surgery, General Sur- gery, and Cardiothoracic Surgery, Hadassah-Hebrew Uni- versity Medical Center, Ein Kerem. Received for publication November 21, 2005; accepted Feb- ruary 16, 2006. Copyright ©2005 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000227736.91811.c7 www.PRSJournal.com 383