MICROSURGERY OF WAR

INTRODUCTION:
In Colombia, South America, we are facing today almost a civil war. The Rural violence and the guerrilla conflict are leaving as sequelae important number of war wounds. A war wound is defined as a wound caused by a high-speed gunshot, antipersonnel fragmentation missile, a  land mine, or any other artifact used for military purposes.
When a war confrontation occurs,  the injured soldiers are attended first in a safe area, and later transported to Regional Hospitals. Sometimes the patients have massive or complicated wounds. These patients are transported to the Military Hospital, in Bogota. Indeed, we have to deal with complex and severely injured patients. In the fields of the reconstructive surgery, the microsurgery is a very important tool to use in these war wounds, we were able to transplant healthy tissue as a free flap to almost any part of the body. Some times the free flaps are used as the best option, but occasionally they are the only option of treatment for these patients.
OBJECTIVES:
The main purpose of the study is to provide evidence that free flaps are worthy options for reconstruction of war wounds, and to compare their outcome with another group of patients with non war wounds.
MATERIAL AND METHODS:
This study provides a retrospective review of 86 free flaps in 84 patients, performed by the senior author in a three year period (August 1996 to November 1999). Also statistics were done of the patients attended in the Military Hospital, the age, type of injury and the treatment. The type of injury was classified in low-speed and high-speed bullets, fragmentation missiles or mines. The time elapsed from the injury to reach the Hospital and the time elapsed to do the final surgical treatment was determined ( acute treatment stated before 30 days). Finally, we took the number of free flaps done and established a comparison between war wound and no war-wound patients.
RESULTS:
From the 525 patients with war wounds at the Military Hospital in the three year period (graphic 1), 367 were treated by the Plastic and Reconstructive Department, with a variety of surgical procedures (graphic 2). The mean age was 22.8 years. The average time elapsed from the injury to reach the Hospital was 5.6 days. All the patients underwent acute surgical reconstruction  (before 30 days), the mean was 15.9 days.
The free flap group was compared with the non-war-wound group requiring free tissue transfer in the same three-year period. 86 free flaps were performed in 84 patients, 32 of them were used for reconstruction of acute war wounds in 32 patients. In the war-wound group, the recipient sites were lower extremity (21 patients), upper extremity (7 patients), and face (4 patients). In the extremities, the flaps were used to provide soft tissue coverage; the bone lengthening was the chosen method for patients (12) with bone defects.

Muscular or musculocutaneous flaps were the choice for lower extremities and fasciocutaneous flaps the choice for upper extremities and face. Two osseocutaneous free flaps were used to restore the mandible in two patients.
Satisfactory results were obtained in 28 of the 32 cases.

Even though free flaps are essential to the reconstruction of severe war wounds, the severity of the damage to the surrounding tissues produced 12.5% failure rate in the 32 free flaps of the acute war-wounded group compared to 0% in the 54 free flaps of the non-war-wound group.
CONCLUSION:
In major and severe trauma, as the war wounds, the free flap reconstruction is a powerful tool. However, the cases must be carefully selected and the flap to use well indicated. The failure rate is higher than the free flaps used in non-war injuries, but is important to understand that these patients have limited or no other options of treatment, as shown in the clinical cases.