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AF surgeons pioneer new medical procedure

SOUTHWEST ASIA -- In Afghanistan, a country plagued by a long history of violence and untold numbers of hidden land mines, limb-threatening injuries occur on a daily basis. For decades, the answer to this tragedy has been the preservation of life over limb by amputation. The presence of open fractures with large soft tissue defects, where there is not enough muscle, fat and skin to cover the broken bone, leaves few treatment options. Wound infections are common when soft tissue coverage is missing and amputation is often the only way to prevent the spread of infection and to save the patient's life. 

With the opening of the new Craig Joint Theater Hospital at Bagram Air Base, and under the leadership of Task Force Med, there is now a medical facility in Afghanistan that is capable of providing state-of-the-art surgical care in a combat theater environment. Microsurgical free tissue transfer is one of the state-of-the-art techniques that is now available at the CJTH. This complex surgical procedure allows surgeons to move a block of tissue from one part of the patient's body to another injured part in order to achieve a functional and aesthetic reconstruction. Microsurgical free tissue transfers, or free flaps, allow patients to heal much more quickly and with less overall deformity or loss of preinjury function than other reconstructive techniques. 

These blocks of tissue may include only a single tissue, such as muscle or bone, or composite tissues, such as muscle, fat and skin, to replace multiple missing tissues at an injury site. In contrast to a simple skin graft, where skin is donated from one part of the body and laid over a wound at another site, a free tissue transfer requires the sewing of blood vessels and sometimes nerves that are often smaller than one millimeter in diameter. This requires magnification, extremely small sutures and excellent surgical dexterity. A free tissue transfer operation may take eight hours or more and, in many respects, is more difficult than an organ transplant. The motivation for performing this complex operation at CJTH is to avoid limb amputation by providing optimal wound coverage for the injured extremity. 

Five microsurgical free tissue transfers have been performed recently at CJTH. The first operation was performed on a 9-year-old girl where one of the 'sixpack' muscles of her abdomen, the rectus abdominis muscle, was transferred to her badly mangled leg. 

The second operation involved the transfer of one of the back muscles, the latissimus dorsi muscle, of a 60-year-old male patient, also to his injured leg. Yet another free tissue transfer involved moving the living fibula bone from one patient's leg to replace both missing bones in one his forearms, thereby preserving function and preventing its amputation. All of these operations were successful, with the free flaps providing muscle coverage and blood supply to the underlying broken bones, allowing them to heal, and avoiding amputation. In the one case, the free flap was the bone itself, allowing the surgical team to replace actual missing skeletal structures. 

Several more candidates for this operation have been identified. A thorough review of the surgical literature found no case reports or series previously published of free autologous tissue transfers performed in
Afghanistan.