Plastic Surgery Challenges in War Wounded I: Flap-Based Extremity Reconstruction

Abstract

Scope and Significance: Reconstruction of traumatic injuries requiring tissue transfer begins with aggressive resuscitation and stabilization. Systematic advances in acute casualty care at the point of injury have improved survival and allowed for increasingly complex treatment before definitive reconstruction at tertiary medical facilities outside the combat zone. As a result, the complexity of the limb salvage algorithm has increased over 14 years of combat activities in Iraq and Afghanistan. Problem: Severe poly-extremity trauma in combat casualties has led to a large number of extremity salvage cases. Advanced reconstructive techniques coupled with regenerative medicine applications have played a critical role in the restoration, recovery, and rehabilitation of functional limb salvage. Translational Relevance: The past 14 years of war trauma have increased our understanding of tissue transfer for extremity reconstruction in the treatment of combat casualties. Injury patterns, flap choice, and reconstruction timing are critical variables to consider for optimal outcomes. Clinical Relevance: Subacute reconstruction with specifically chosen flap tissue and donor site location based on individual injuries result in successful tissue transfer, even in critically injured patients. These considerations can be combined with regenerative therapies to optimize massive wound coverage and limb salvage form and function in previously active patients. Summary: Traditional soft tissue reconstruction is integral in the treatment of war extremity trauma. Pedicle and free flaps are a critically important part of the reconstructive ladder for salvaging extreme extremity injuries that are seen as a result of the current practice of war.

Keywords: extremity reconstruction; extremity trauma; flap coverage; microsurgery; soft tissue injury; tissue transfer.

Ian L. Valerio, MD, MS, MBA, FACS

Figure 1.

(a) Left hand injury before flap coverage. (b) Same left hand injury status post-coverage with a first dorsal metacarpal artery flap. To see this illustration in color, the reader is referred to the web version of this article at www.liebertpub.com/wound

Figure 2.

(a) Left upper extremity composite type injury involving soft tissue deficits (skin, subcutaneous tissue, and muscle) and fractured humerus. (b) Same left upper extremity composite type injury with coverage of stabilized bone fracture and functional myocutaneous latissimus flap to restore soft tissue and muscle deficits in combination with skin grafting. To see this illustration in color, the reader is referred to the web version of this article at www.liebertpub.com/wound

Figure 3.

(a) Left upper extremity consisting of segmental median nerve defect and complex soft tissue injuries. (b) Left upper extremity reconstruction after liposculpting for contour improvement and 2 years after definitive coverage with an anterolateral thigh flap, DRT, split-thickness skin grafting, and allograft and autologous nerve grafting showing finger extension functional outcome. (c) Same extremity injury after reconstruction showing flexion functional outcome. (d) Same extremity injury after reconstruction showing elbow function. DRT, dermal regenerate template. To see this illustration in color, the reader is referred to the web version of this article at www.liebertpub.com/wound

Figure 4.

(a) Right upper extremity defect with exposed carpus and flexor tendons before groin flap and DRT. (b) Right upper extremity injury with pedicle right groin flap coverage before division. (c) Same right upper extremity injury after groin flap division, inset and skin grafting. (d) Second view of same right upper extremity injury after groin flap division, inset and skin grafting. To see this illustration in color, the reader is referred to the web version of this article at www.liebertpub.com/wound

Figure 5.

(a) Right lower extremity blast trauma with soft tissue and orthopedic injuries. (b) Right lower extremity injury status post-coverage with free microvascular latissimus flap transfer. (c) Same right lower extremity reconstruction after latissimus flap coverage and split-thickness skin grafting greater than 1,200 cm². (d) Same right lower extremity 3 years post-definitive reconstruction. To see this illustration in color, the reader is referred to the web version of this article at www.liebertpub.com/wound

Figure 6.

(a) Right lower extremity residual limb below knee amputation before salvage with free latissimus flap. (b) Same right lower extremity BKA salvage case showcasing myocutaneous latissimus flap harvest. (c) Same right lower extremity BKA salvage after inset of free latissimus flap and skin grafting. BKA, below the knee amputation. To see this illustration in color, the reader is referred to the web version of this article at www.liebertpub.com/wound