Microvascular Tissue Transfer in the War Wounds Treatment

Introduction: War wounds caused by modern infantry weapons or explosive devices are very often followed by defects of various tissues. In accordance with war surgical doctrine at the Clinic for Plastic Surgery and Burns, we used free flaps in treating wounded with vast tissue defects. With an aim of closing war wounds, covering deep structures or making the preconditions for later reconstruction of deep structures, we applied the free flaps. The main criteria for using free flaps were: general condition of wounded, extent, location, and structure of tissue defects.

Methodology and Material: These war-wounds were accompanied by various tissue defects in over 50% of the wounded. In more than two-thirds of the wounded patients treated at our clinic, the structure of the war-wounds tissue defects was complex, therefore the surgical treatment of these wounds often required a multi-disciplinary procedure and a joint work of various surgeons-specialists usually with orthopaedists.

The surgical treatment of war-wounds accompanied by tissue defects consists of primary or secondary excision of devitalized tissue, delayed closure of the wounds as well as of secondary reconstructure of deep structures. An adequate primary excision of devitalized tissue makes the delayed closure of the wound possible. A proper closure provides the conditions necessary for secondary reconstructions of deep structures. Reconstructive microsurgery had fined application in the treatment of wounded from civil war in The Former Yugoslavia. Microvascular transplantation of free flaps was first time performed in the history of Yugoslav medicine for the treatment of war wounds with various tissue defects. In the epidemic situation of war trauma, followed by skin and soft tissue defects, it was possible to perform transplantation of large, free flaps of various structures by microvascular technique in one act operation.

Results: We analyzed free flaps that we applied. After free flap transfer we performed (16,6%) revisions, and after (9,2%) unsuccessful revisions we applied another free flaps in (2,5%) patients, local skin flap in (0,8%) patient, cross leg flaps in (4,2%) patients, or performed below knee amputation in (1,6%) patients.

Conclusions: The aim of free flap application in wounded with various tissue defects was different according to the phase of surgical treatment. In the first phase of the surgical treatment the aims are: defect closing, deep structure covering and forming prerequisites for secondary reconstruction of the deep structures. That is why free flaps with skin component-skin island, were used in this early phase of the treatment. In the second phase of the surgical treatment - the phase of the reconstruction of the deep structures, the aim of the microvascular tissue transplantation was compensation of deep tissue structures, usually bone tissue. In this late phase of surgical treatment, phase of reconstruction of the deep structures free flaps with bone component or vascularized bone grafts were used The advantages of the free flap transfer are single act surgical procedure, shorter closing period of war wounds with vast tissue defects and earlier beginning of physical therapy of wounded and the disadvantages are long duration of surgical procedures and the facta that microsurgical equipment and trained microsurgical team are required.