Plastic Surgery at War: A Scoping Review of Current Conflicts

Surgical Capacity Assessment and Leverage in the Palestinian Land (SCALPEL-I) Study: The First Nationwide Plastic Surgery Capacity Evaluation in Palestine

Background

Access to surgical care in low-to-middle-income countries (LMICs), especially in war-torn areas such as the occupied Palestinian territory (oPt), is a global health priority. The plastic surgical capacity in the oPt has not been evaluated. This study provides the first systematic evaluation of plastic surgical capacity in the oPt.

Methods

A cross-sectional study conducted between December 2022 and February 2023 included facilities providing plastic surgery services in the oPt, except private centers run by nonsurgeons. A modified PIPES (personnel, infrastructure, procedures, equipment, and supplies) tool was used. Data were analyzed for geographic and private/public disparities.

Results

Eleven facilities were included; 6 (54.5%) were in the West Bank and 5 (45.5%) in Gaza. The majority were private hospitals (n = 6, 54.5%). The mean PIPES score was personnel = 4.3 (4.03), infrastructure = 18.4 (2.4), procedures = 9.8 (3.8), equipment = 19.2 (3.6), and supplies = 22.4 (1.9). Hospital beds, operating rooms, and plastic surgeons per 100,000 people were 33.5, 1.0, and 0.5, respectively. There were 8 board-certified plastic surgeons. No facilities had a plastic surgery residency program. Key deficiencies included: 8 facilities (72.2%) not performing microsurgical free tissue transfers (none in Gaza), 5 (45.5%) lacking a system to identify complications, and 7 (63.3%) not offering regular educational courses. Average power supply was 8.0 hours/day in Gaza and 24.0 hours/day in the West Bank.

Conclusions

Plastic surgical capacity in the oPt shows significant deficiencies, especially in Gaza. These findings should inform stakeholders to address disparities, develop training programs, and improve access to safe plastic surgery.

Balancing Expectations: Navigating Medically Necessary Torso Procedures with Cosmetic Components in the Military Healthcare System

Background

Surgeons performing federal insurance-financed procedures involving medically necessary and cosmetic components must navigate patient expectations to avoid postoperative disappointment. This challenge is amplified in military healthcare, where different surgical specialties concurrently address the same diagnosis, while the Department of Defense policy on cosmetic fees and TRICARE's definition of excluded services adds further complexity. With the increasing prevalence of elevated body mass index, focus is directed toward diagnoses involving the torso, specifically gynecomastia in male individuals, and diastasis of the rectus abdominis muscles (DRAM) in female individuals.

Methods

The study involves a team of experienced board-certified surgeons conducting a narrative review of surgical procedures addressing gynecomastia and DRAM. Relevant literature from 2000 to 2023 is reviewed, focusing on patient satisfaction regarding outcome of medically necessary and cosmetic aspects.

Results

For gynecomastia, distinguishing between true and pseudogynecomastia is critical. A protocol is presented based on the Simon classification, offering evidence-based guidelines for surgical interventions. Similarly, for DRAM, a minimally invasive approach balances deployment readiness and surgical recovery. The presence of a symptomatic panniculus, however, requires more invasive intervention. The downstream ramification of limited Current Procedural Terminology codes for these interventions is discussed.

Conclusions

In medically necessary procedures funded through federal health plans such as TRICARE, the primary goal is functional improvement, not the final torso contour. Clear communication and preoperative counseling are crucial to managing patient expectations. Providers in military healthcare must navigate the complex landscape of patient expectations, policy guidelines, and duty readiness while maintaining the standard of care.

The integration of ortho-plastic limb salvage teams in the humanitarian response to violence-related open tibial fractures: evaluating outcomes in the Gaza Strip

BACKGROUND

Limb salvage by ortho-plastic teams is the standard protocol for treating open tibial fractures in high-income countries, but there's limited research on this in conflict settings like the Gaza Strip. This study assessed the clinical impact of gunshot-related open tibial fractures, compared patient management by orthopedic and ortho-plastic teams, and identified the risk factors for bone non-union in this context.

METHODS

A retrospective review of medical records was conducted on Gaza Strip patients with gunshot-induced-open tibial fractures from March 2018 to October 2020. Data included patient demographics, treatments, and outcomes, with at least one year of follow-up. Primary outcomes were union, non-union, infection, and amputation.

RESULTS

The study included 244 injured individuals, predominantly young adult males (99.2%) with nearly half (48.9%) having Gustilo-Anderson type IIIB fractures and more than half (66.8%) with over 1 cm of bone loss. Most patients required surgery, including rotational flaps and bone grafts with a median of 3 admissions and 9 surgeries. Ortho-plastic teams managed more severe muscle and skin injuries, cases with bone loss > 1 cm, and performed less debridement compared to other groups, though these differences were not statistically significant. Non-union occurred in 53% of the cases, with the ortho-plastic team having the highest rate at 63.6%. Infection rates were high (92.5%), but no significant differences in bone or infection outcomes were observed among the different groups. Logistic regression analysis identified bone loss > 1 cm, vascular injury, and the use of a definitive fixator at the first application as predictors of non-union.

CONCLUSIONS

This study highlights the severity and complexity of such injuries, emphasizing their significant impact on patients and the healthcare system. Ortho-plastic teams appeared to play a crucial role in managing severe cases. However, further research is still needed to enhance our understanding of how to effectively manage these injuries.

The use of machine learning for investigating the role of plastic surgeons in anatomical injuries: A retrospective observational study

While plastic surgeons have been historically indispensable in the reconstruction of posttraumatic defects, their role in trauma centers worldwide has not been clearly defined. Therefore, we aimed to investigate the contribution of plastic surgeons in trauma care using machine learning from an anatomic injury viewpoint. We conducted a retrospective study reviewing the data for all trauma patients of our hospital from March 2019 to February 2021. In total, 4809 patients were classified in duplicate according to the 17 trauma-related departments while conducting the initial treatment. We evaluated several covariates, including age, sex, cause of trauma, treatment outcomes, surgical data, and severity indices, such as the Injury Severity Score and Abbreviated Injury Scale (AIS). A random forest algorithm was used to rank the relevance of 17 trauma-related departments in each category for the AIS and outcomes. Additionally, t test and chi-square test were performed to compare two groups, which were based on whether the patients had received initial treatment in the trauma bay from the plastic surgery department (PS group) or not (non-PS group), in each AIS category. The department of PS was ranked first in the face and external categories after analyzing the relevance of the 17 trauma-related departments in six categories of AIS, through the random forest algorithm. Of the 1108 patients in the face category of AIS, the PS group was not correlated with all outcomes, except for the rate of discharge to home (P < .0001). Upon re-verifying the results using random forest, we found that PS did not affect the outcomes. In the external category in AIS, there were 30 patients in the PS group and 56 patients in the non-PS group, and there was no statistically significant difference between the two groups when comparing the outcomes. PS has contributed considerably to the face and external regions among the six AIS categories; however, there was no correlation between plastic surgical treatment and the outcome of trauma patients. We investigated the plastic surgeons' role based on anatomical injury, using machine learning for the first time in the field of trauma care.

The Air Force Visiting Surgeon Program: Development, Outcomes, and Future Application

INTRODUCTION

Active duty service members and their families have limited access to subspecialty surgical care when assigned OCONUS. To address this issue, the Air Force Visiting Surgeon Program (VSP) was created to push subspecialty care to these locations. Visiting Surgeon Program was accomplished using temporary duty (TDY) orders. We conducted this 12-year review, 2009-2021, of the program to assess objective measures of impact, identify key lessons learned, and consider the program's future.

MATERIALS AND METHODS

In 2009, the senior author, Col Latham, performed a cost analysis of plastic surgery care provided at OCONUS installations and found that TRICARE Overseas often paid rates substantially higher than a TDY assignment for a single procedure. To improve beneficiaries' access to care while providing a cost savings to the health care system, 2-week plastic surgery missions were proposed to interested OCONUS military treatment facilities (MTFs). Ultimately, four sites selected to host the program in Alaska, Italy, England, and Japan. These sites were selected based on patient volumes, operating room capacity, and local command and surgeon support. By 2015, the Air Force formalized the program via Air Force Instruction 44-102 which outlined roles and responsibilities of MTF Commanders; established points of contact; and instituted key safety measures.

RESULTS

To date, 58 missions have been completed by 21 surgeons through the VSP at Aviano Air Base (Italy; 24.1%), Joint Base Elmendorf-Richardson (Alaska; 31.0%), Royal Air Force Lakenheath (England; 27.6%), and Yokota Air Base (Japan; 17.2%). While primarily an Air Force program, 17% (10/58) of missions were supported Army or Navy surgeons. Overall, 2,000 patient consultations and 865 surgical cases were performed avoiding $6.7 million in cost. In addition to direct beneficiary care, the VSP also contributed to the participating surgeon and host surgical teams mission readiness.

CONCLUSIONS

The VSP provides a template to make select subspecialty surgical care available in a cost-effective manner across the military health system, while also providing a model for the forward deployment of military plastic surgeons and triservice collaboration.

Combating the "Peacetime Effect" in Military Plastic Surgery: Implications for Mission Readiness

Military treatment facility-assigned surgeons face numerous challenges in maintaining critical wartime skills, including the "peacetime effect" and the "dual mission." Using the field of plastic surgery to illustrate these issues, we contrast plastic surgeons' contributions to combat casualty care with primary data describing plastic surgeons' clinical practice in many military hospitals. Then, we outline the current administrative mechanisms being promoted at the enterprise-level for surgeons to gain a more mission-focused, clinical practice, while also examining significant shortcomings in these policies. Finally, we conclude with a call to action for the military surgical community to accelerate change in the development of more robust clinical practices for our surgeons, or potentially lose our ability to field a ready surgical force.