American Society of Plastic Surgeons
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Military Plastic Surgery in Modern Times

Global War on Terrorism (GWOT)


  • Wound epidemiology
  • Evacuation chain
  • Plastic surgeon contributions

Wound Epidemiology

Blast Injury

  • Primary
    • Blast overpressure causes direct damage
    • Pulmonary contusion/edema/air emboli
    • Gastrointestinal ischemia or perforation
    • Auditory canal/ear drum perforation
    • Extremity compartment syndrome?
  • Secondary
    • Displaced debris
  • Tertiary
    • Being thrown

Gunshot Wounds

  • Surface wound can mask larger wound
  • Debridement of devitalized tissue
  • Fasciotomy needed in most cases

Wound Contamination

  • Gram negative most common
    • Acinetobacter, Klebsiella
    • Drug resistance is common
  • Infections more common
    • Blast injury
    • Higher injury severity scores
    • Battle vs non-battle injury
  • Increases morbidity and mortality

After Injury: Evacuation Chain

  • Goal: Triage, treat, evacuate and return the casualty to duty in the most time-efficient manner
    • Preserve the fighting force

Evacuation Chain: Echelon I

  • Point of injury care
  • Squad member, medic, GMO
  • Battalion Aid Station
    • RTD or stabilize and evacuate

Evacuation Chain: Echelon II

  • Acute and limited primary care
  • Ancillary services, if augmented
  • Hold up to 72-hrs before RTD
  • May have blood/surgical capacity
  • Forward Surgical Team(s)
    • 20-person teams, including GS/Ortho
    • Max is 30 operations in 72 hours
    • Goal: Resuscitative surgery in patients who cannot be evacuated

Evacuation Chain: Echelon III

  • Combat Support Hospital
  • USNS hospital ships
  • Full surgical, inpatient and critical care support

Evacuation Chain: Echelon IV

  • Landstuhl, Germany
  • Tertiary care hospitals located outside CONUS

Evacuation Chain: Echelon V

  • Tertiary care facilities within CONUS
  • Walter Reed National Military Medical Center
  • Brooke Army Medical Center
  • Naval Hospital San Diego

OIF/OEF: Plastic Surgeon Contributions

Brooke Army Medical Center

  • Eight patients had free flap
    • Exposed skull
    • Upper or lower extremity
  • Flap selection
    • Radial forearm
    • Latissimus dorsi
  • Complications
    • Infection and hematoma most common

Naval Medical Center San Diego

  • 27 patients/27 free flaps
    • Facial wounds
    • Upper or lower extremity
  • Flap selection
    • Rectus abdominis
    • Latissimus dorsi
    • Others (serratus, scapular, ALT)
  • Complications
    • Infection/osteomyelitis were common

Walter Reed

  • 43 patients had free flap
    • Lower extremity
  • Flap selection
    • Latissimus dorsi
    • ALT
    • Rectus
    • Others (serratus, lateral arm)
  • Complications
    • Infection common

  • 156 patients had cranioplasty
  • Reconstruction
    • 3D CT
    • Custom alloplastic implant fabrication "in house"
    • Secondary procedures to address soft tissue defects

Walter Reed: Approach to Cranioplasty

Walter Reed: Approach to Lower Extremity

OEF/OIF – Summary Points

  • Microvascular free tissue transfer playing a growing role in care of the wounded soldier
  • Body armor serves as a "free flap protector"

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