Quality of Life Indicators in Patients Operated on for Breast Cancer in Relation to the Type of Surgery-A Retrospective Cohort Study of Women in Serbia.

Background and objectives: Quality of life (QoL) after breast cancer surgery is an important public health issue. The aim of this study was to determine the relationship between the levels of perceived quality of life in patients operated on for breast cancer in relation to the type of surgery, using the standardized questionnaires. Materials and Methods: We assessed 425 women after surgery for breast cancer. The assessment included the application of the WHOQOL-bref (The World Health Organization Quality of Life-Bref), and FACT-B (Functional Assessment of Cancer Therapy-Breast) questionnaires. The statistical analysis of the data included multiple linear regression and correlation tests. Results: Multiple linear regression analysis found that education, existence of comorbidities, time elapsed since surgery, and type of surgery were significant predictors of overall quality of life. Women's overall quality of life and general health has increased by 0.16 times for each subsequent year of surgery, and by 0.34 times for each subsequent higher education level. Breast-conserving surgery or mastectomy with breast reconstruction were statistically significant (ß = 0.18) compared to total mastectomy. Conclusions: There is a significant difference in the quality of life perceived by patients in whom the breast has been preserved or reconstructed in relation to patients in whom total mastectomy has been performed.

Platelet gel in wound treatment in patient with pemphigus vulgaris and Type 2 diabetes mellitus: Case report.

Treatment of wounds, especially in patients with systemic diseases, is very difficult and time consuming, and it represents great challenge. Complications like infections and impaired healing are regularly seen in these patients, sometimes leaving almost no other treating option, but amputation surgery. In wound healing process, platelets play one of key roles, both in hemostasis, and, by releasing many growth factors, in reepithelization and tissue remodeling. Platelet concentrates are defined as autologous or homologous platelet derivatives with a platelet concentration higher than it is usually in human blood. Concentration of platelets needed to affect wound healing should be 1,000,000/µl. This is a report about patient with pemphigus vulgaris and Type 2 diabetes mellitus, who got injury of the left lower leg. Traditional surgical methods of wound closure and vacuum-assisted closure therapy were ineffective. Homologous platelet gel was used topically, resulting in wound closure, without any adverse effects.

Validity of ultrasound-guided aspiration needle biopsy in the diagnosis of micrometastases in sentinel lymph nodes in patients with cutaneous melanoma.

Background/Aim: Cutaneous melanoma is one of the most aggressive solid cancers, that develops local, regional and distant metastases. The presence of metastases in lymph nodes is in correlation with Breslow tumor thickness. According to various researches, in melanoma with more than 4 mm Breslow thickness, lymph node micrometastases can be found in 60-70% of cases. Sentinel lymph nodes biopsy is a diagnostic procedure for lymph node micrometastasis detection, which is necessary for disease staging. In recent studies, ultrasound-guided fine needle aspiration with cytology (US FNAC) of the sentinel lymph node was used as less invasive procedure, but is not accepted as the standard procedure. The goal of this work was to define sensitivity, specification and precision of the ultrasound-guided fine needle aspiration method in comparison with standard sentinel lymph node biopsy. Methods: After obtaining the Ethics Committee's permission, from 2012 to 2014 a total of 60 patients with cutaneous melanoma were enrolled, and divided into three groups: group I with thin melanoma, group II with intermediate thickness melanoma and group III with thick melanoma. The presence of micrometastases in sentinel regional lymph nodes was analyzed by US FNAC. The results obtained were compared to sentinel lymph nodes biopsy (SLNB) results. The golden standard for calculating the specific, sensitive and precise characteristics of the method of US FNAC of sentinel lymph nodes was histopathologic lymph node examination of sentinel lymph nodes acquired through biopsy. Results: Detection rate of US FNAC was 0% in the group I, 5% in the group II and 30% in the group III. SLNB detection rates were: 10% in the group I, 15% in the group II, and 45% in the group III. In melanoma thicker than 4 mm, 15% of the patients were false negative by US FNAC. The sensitivity of US FNAC for all the patients was 50%: in the group I, 0%; in the group II, 33.3%; and in the group III, 66.6%. The method specificity for all examined patients was 100% and accuracy 88%: group I, 90%; group II, 90%; group III, 85%. The FNAC and SLNB micrometastasis detection rate was significantly higher in melanoma with Breslow thickness > 4 mm (group 3) in comparison to thin and intermediate thickness tumors. Conclusion: The method of ultrasound-guided fine needle aspiration of sentinel lymph nodes, according to its sensitivity, has a place in the diagnostics of micrometastasis in regional lymph nodes only in thick melanoma, but not in thin and intermediary thickness melanoma. The results must be confirmed in a larger number of patients. If this observation could be confirmed, it would rationalize treatment of patients with thick melanoma, decrease the number of operations and shorten the time to make the diagnosis.

Surface enlargement of a new arterialised venous flap by the surgical delay method.

BACKGROUND/AIM: The delay method is a surgical, pharmacological and combined method that includes two or more time separated phases, which gives bigger flap surface. In our research we explored the possibility of flap surface enlargement in a new arterialised venous flap (AVF) on an experimental rabbit ear model by the delay surgical method. The aim of this research was to establish vitality surface of our AVF and to maintain the difference in flap vital surface between AVF flaps, with or without performing the delay surgery method. METHODS: We used both ears of "Big Chinchilla" rabbits in 10 experimental male animals, divided into two groups, average weight 3-3.5 kg, and average age 8-10 months. In the first (experimental) group, a venous flap was arterialised by our method. In the second (control) group, the venous flap was arterialised 14 days after the delay surgical method. AVF surface was measured on the 1 and 14 days by the method of trapezoid rule. RESULTS: Vital surface on our AVF experimental model was bigger than 87% of elevated flap surface after the delay surgical method. Vital surface on AVF without delay on our experimental model was bigger than 30% of elevated flap surface (p < 0.001). CONCLUSION: Analysis of previous experimental models on the rabbit ear, non-delayed and delayed (to enlarge flap surface) led us to conclusion that previously created experimental models of non-delayed AVF are hemodynamically negative. Our experimental non-delay AVF model is hemodynamically more positive than previously created models of non-delay AVF and provides better conditions for AVF survival and enlargement of vital flap surface of elevated flap. On the other hand, surgical delay method significantly enlarges vital surface of AFF.

Surgical treatment of hand vascular anomalies--a case report.

BACKGROUND: Vascular anomalies in the hand do not occur frequently. Their presence in the metacarpal region can cause different functional disorders. The extent of such disorders directly depends on the localization and size of vascular anomalies, duration and the nature of the anomaly growth as well as on eventual secondary complications such as ulceration or bleeding. The aim of this case report was to show the specifics in the clinical picture, pathogenesis and evolution of such anomalies, applied diagnostic procedures (radiography, ultrasound, magnetic resonance, electromyography) and surgical treatment as well as postoperative functional results. CASE REPORT: In the Clinic for Plastic Surgery and Burns, Military Medical Academy Belgrade, two patients were treated surgically for vascular anomalies of the middle palmar region of the hand. The first patient, a 36-year-old male, a former active sportsman (professional handball player) was treated for acute increase in the vascular anomaly of hand in the metacarpal region and proximal phalange of III and IV fingers of his right hand. The anomaly was detected 6 months prior to his hospitalization while two weeks before the hospitalization there was a sudden growth and increase in the change. The second case, a 15-year-old male patient actively pursuing a career in professional basketball was treated for a tumor localized in the metacarpal zone of his left hand. According to the information provided by his parents, the anomaly had been present since his birth. Initially, the anomaly manifested itself as a discoloration of the skin with a marked capillary drawing, gradually increasing throughout the last five years to the present dimension. The growth of the malformation was noticed to coincide in both patients with more active pursuit of their professional sports career. CONCLUSION: The clinical picture of hand vascular anomalies is dominated by the symptoms of compression of neurovascular structures (paresthesia, intense hand pain, swollen fingers). If it is a chronic progressive process, signs of ischemic intrinsic muscle fibrosis with corresponding functional deficit, as well as tissue defect (usura) of bone and joint structures represent the basic pathological findings. Acute increase is accompanied by compartment syndrome symptoms and ischemic fibrosis of intrinsic hand musculature and development of irreversible dysfunction of the hand. In the presented cases rapid response implies accurate diagnostic methods followed by surgical extirpation in order to treat compartment syndrome.

[Using vacuum in the treatment of surgical wounds complications].

BACKGROUND/AIM: Using vacuum in medicine has been known from long ago, however, it has not been used for the treatment of wounds. The first experiments in this field were performed by Wagner Fleischmann, University of Ulm, Ulm, West Germany, in 1993. The aim of this study was to present our clinical experience with the treatment of surgical wounds complications in vascular patients by the use of controled vacuum. METHOD: In a period October 2006 - December 2009 a total of 18 patients with infection and surgical wound dehiscence were treated by the use of vacuum. Vacuum was applied to wounds by placing a polyurethane sponge on them and by fixing a polyurethane foil and a sponge to the surrounding healthy skin so to completely airtight wounds. Over a foil vacuum of--150 mmHg was applied for a 5-day period, and on the day 6 a foil and a sponge were removed. RESULTS: In all the 18 wounds treated by the use of vacuum secondary wound closing was achieved with no complications and with a significantly shortened time period treatment. Wound infections were healed using this method and only in 2 patients antibiotics were used at the same time. CONCLUSION: The use of vacuum in the treatment of operative wounds complications is an easy and reliable method contributing significantly to wounds better healing.

Epidemiology of nosocomial colonization/infection caused by Acinetobacter spp. in patients of six surgical clinics in war and peacetime.

BACKGROUND/AIM: Acinetobacter spp. has emerged as nosocomial pathogen during the past few decades in hospitals all over the world, but it has increasingly been implicated as a serious nosocomial pathogen in military hospitals. The aim of this study was to analyse and compare the surveillance data on Acinetobacter nosocomial colonization/infection (NCI) collected during the wartime with the data collected in peacetime. METHODS: We conducted a prospective study of incidence of Acinetobacter spp. colonization/infection. Also, the two nested case-control studies were conducted. The patients with nosocomial infection (cases) were compared with those with nosocomial colonization (controls) during the two different periods, wartime and peacetime. The patients with NCI by Acinetobacter spp. were identified by the case-based surveillance. The surveillance covered all the patients in 6 surgical clinics. RESULTS: During the study periods a total of 166 patients had cultures that grew Acinetobacter spp. and the pooled rates of Acinetobacter spp. colonization and infection were significantly higher in wartime. When patients with NCI in wartime were compared with those with NCI in peacetime significant differences were observed. In the war year, the patients were more significantly males (p < 0.000). In a period of peace, most of the colonization/infections were reported from patients with certain chronic diseases (p = 0.020) and the survival of patients was more significant (p = 0.049). During the peacetime, proportions of Acinetobacter isolates resistent to ciprofloksacin, imipenem and meropenem were significantly higher (p < 0.001). CONCLUSION: This study provides additional important information about the risk factors of nosocomial Acinetobacter spp. infections in a large cohort of surgical patients. This is also the first study that directly examines epidemiological differences between NCI caused by Acinetobacter spp. during the war and peace period.

Principles of surgical treatment of congenital, developmental and acquired female breast asymmetries.

BACKGROUND/AIM: There is a natural asymmetry in normal female brests. When the difference in the shape, size or position of the breast and nipple-areola complex is visible, surgical correction is the only treatment option and presents one of the greatest challenges for a plastic surgeon. Based on the Nahai classification presented in details, the aim of the study was to present the possibilities of plastic surgery to correct primary (congenital), secondary (developmental) and tertiary (acquired) brest asymmetries. METHODS: We conducted a retrospective analysis of female breast asymmetry surgeries performed in the Clinic for Plastic Surgery and Burns, Military Medical Academy (MMA), Belgrade over the last seven years (January 2002 - January 2009). RESULTS: During the above mentioned period, 82 female patients, 18 - 65 years of age, underwent surgery for breast asymmetry. The most frequent asymmetries were developmental, "pubertal" (n = 43); acquired asymmetries as a consequence of tumor surgery were found in the other 22 patients, while 7 patients were diagnosed with primary asymmetries such as congenital chest-wall asymmetry (Sy. Poland), accessory and tuberous breasts. All patients underwent preoperative ultrasound examination, while hormone status was determined in those with developmental, "pubertal" asymmetries. The selection of surgical procedure for correction of breast asymmetry depended upon clinical examination findings and patient's wish relating to the shape and size of the breasts. The most of breast asymmetries were corrected by a combination of surgical procedures including primary and secondary reconstruction, reduction, suspension or augmentation mammoplasty. Having combined different surgical procedures, we managed to achive satisfactory results. The hypertrophic scar formation after reduction mamoplasty was seen in some cases, however, they caused no significant patient's discomfort. CONCLUSION: Application of plastic, reconstructive and aesthetic surgical principles can considerably contribute to achieving excellent results in corrective surgery for breast asymmetries. In addition to most suitable breast asymmetry surgical procedures choice, motivation of a patient is also very important for achieving satisfactory results.

[Ultrasonographic findings validity in the identification of metastatic regional lymph nodes in patients with cutaneous melanoma].

UNLABELLED: BACKGROUND/AIM. Early identification of lymph node (LN) metastases has both therapeutic and prognostic significance in patients with cutaneous melanoma. Ultrasonographic (US) examination of LN morphological characteristics and US of LN morphological and vascular characteristics are diagnostic methods used in identification of regional LN metastases, thus rendering a base for lymphonododisection indication. The aim of this study was to determine validity of these two US diagnostic methods and eventual statistically significant difference between them. METHODS. The study included the two groups of the patients with clinical stage III melanoma. The group I included 31 patients followed up by the use of US of LN morphological characteristics due to the fact that US findings described them only. The group II included 30 patients in whom morphological and vascular LN characteristics were followed up. The patients of both groups were examined in the Institute for Radiology, Military Medical Academy using an ultrasonographic unit type Akuson Sequoia Model 2000. After that, therapeutic and elective radical disections were performed. Sensitivity, specificity and accuracy of US examination of LN were checked by histopathological examination. RESULTS: The presence of LN metastases in the group I was suggested by LN enlargement and its extent, while in the group II it was suggested by the ratio of LN length and width in 83.3% of the patients, echogenicity of LN center in 76.7% of the patients, LN resistance index in 73.3% of the patients, pathologic LN vascularization in 86.7%, and pathologic intranodal arborization in 83.3% of the patients. In 67.7% of the patients in the group I and in 93.3% of the patients in the group II matastatic changes of LN were diagnosed by pathohistology. A difference between validities of the two groups was statistically significant (p < 0.05). CONCLUSION: LN size without other US morphological and vascular characteristics of LN does not provide enough valid US finding for a reliable preoperative identification of LN with metastatic changes in patients with cutaneous melanoma.

[Anatomic and histological characteristics of vagina reconstructed by McIndoe method].

BACKGROUND/AIM: Congenital absence of vagina is known from ancient times of Greek. According to the literature data, incidence is 1/4 000 to 1/20 000. Treatment of this anomaly includes non-operative and operative procedures. McIndoe procedure uses split skin graft by Thiersch. The aim of this study was to establish anatomic and histological characteristics of vagina reconstructed by McIndoe method in Mayer Küster-Rockitansky Hauser (MKRH) syndrome and compare them with normal vagina. METHODS: The study included 21 patients of 18 and more years with congenital anomaly known as aplasio vaginae within the Mayer Küster-Rockitansky Hauser syndrome. The patients were operated on by the plastic surgeon using the McIndoe method. The study was a retrospective review of the data from the history of the disease, objective and gynecological examination and cytological analysis of native preparations of vaginal stain (Papanicolau). Comparatively, 21 females of 18 and more years with normal vaginas were also studed. All the subjects were divided into the groups R (reconstructed) and C (control) and the subgroups according to age up to 30 years (1 R, 1C), from 30 to 50 (2R, 2C), and over 50 (3R, 3C). Statistical data processing was performed by using the Student's t-test and Mann-Writney U-test. A value of p < 0.05 was considered statistically significant. RESULTS: The results show that there are differences in the depth and the wideness of reconstructed vagina, but the obtained values are still in the range of normal ones. Cytological differences between a reconstructed and the normal vagina were found. CONCLUSION: A reconstructed vagina is smaller than the normal one regarding depth and width, but within the range of normal values. A split skin graft used in the reconstruction, keeps its own cytological, i.e. histological and, so, biological characteristics.

Some biological characteristics of transferred free flaps.

At the Clinic for plastic surgery and burns of the MMA, we examined 33 patients with transferred 5 cutaneous, 18 myocutaneous, and 10 osteocutaneous free flaps out of which 10 were done on foot, 13 on the lower leg, and 10 on the face. We analyzed the blood circulation (patency of arterial microanastomosis and perfusion) of transferred free flaps, recovery of sensitivity, functioning of the sebaceous and sweat glands as well as histomorphologic changes in the skin of the transferred free flaps during the period of 6 up to 36 months after the free flap transfer and compared with the same characteristics of the skin and tissue of the surrounding area of the recipient region.

[Microvascular osteoseptocutaneous radial flap in reconstruction of mandible following war injury].

BACKGROUND: Vascularized osteoseptocutaneous radial flap is commonly used in the reconstruction of composite bony and soft tissue defects of the lower third of the face due to the outstanding quality of its cutaneous component. The aim was to evaluate the primary and overall success in the reconstruction of mandibular defects, following war injuries, with vascularized osteoseptocutaneous radial flap. METHODS: At the Department of Maxillofacial Surgery of the Military Medical Academy Belgrade, there were eight patients with this kind of defect following war injury, and the mandible was reconstructed with a vascularized osteoseptocutaneous radial flap. Bony compartment of the graft was harvested as up to 11 cm long segment of radial circumference. RESULTS: The localization and structure of the defect, features of a harvested compound graft, the procedure of the reestablishment of the mandibular continuity was presented as well as immediate and late complications during the consolidation period, and the primary successful reconstruction in 87.5% of the patients. CONCLUSION: The primary and overall success in the mandibular defects reconstruction with a vascularized osteoseptocutaneous radial flap was equal or even better than those presented in the literature on the reconstruction of the similar defects after tumor resections.

[Breast reconstruction by pedicled transverse rectus abdominis myocutaneous flap]. / Rekonstrukcija dojke peteljkastim transverznim miokutanim reznjem m.rectus abdominisa.

Reconstruction of the amputated breast in female patients after surgical management of breast carcinoma is possible with the use of autologous tissue, synthetic implants, or by combining autologous tissue and synthetic materials. Autologous tissue provides soft and sufficiently elastic tissue, which is usable for breast reconstruction and eventually obtains original characteristics of the surrounding tissue on the chest wall. The use of the TRAM flap for breast reconstruction was introduced in 1982 by Hartrampf, Scheflan, and Black. The amount of the TRAM flap tissue allows breast reconstruction in the shape most adequate to the remaining breast. The possibilities of using the TRAM flap as pedicled myocutaneous flap or as free TRAM flap make this flap a superior choice for breast reconstruction in comparison with other flaps.

[Plastic surgery in the treatment of primary cutaneous melanoma]. / Plasticna hirurgija u lecenju primarnog melanoma koze.

Surgery is still the most effective treatment modality of skin melanoma. The margins of excision are determined by the thickness of primary tumor. From January 1999 to December 2001, 99 patients (57 male and 42 female, of the average age 55), were surgically treated at the Clinic for Plastic Surgery and Burns of the Military Medical Academy. The most usual localization of the primary tumor was the back (23.23%), followed by the forearm, and the lower leg. Regarding the clinical type of the melanoma, nodular melanoma dominated (62.62%). Microscopic staging of the melanoma (classification according to Clark and Breslow), showed that the majority of patients already suffered from the advanced primary disease, which called for radical excision and the choice of reconstructive methods in the closure of post-excision defects. The reconstructive plastic surgical methods enabled the closure of post-excision tissue defects, regardless of their size, structure, and localization. During the closure of post-excision defects, direct wound closure or split skin draft was performed in 76.76% of patients. Flaps were applied in 19.19% of patients with the primary melanoma of the head, face, foot, and hand. The sufficiency of the available reconstructive procedures makes plastic surgery irreplaceable in the surgical treatment of the primary melanoma of the skin.

[Surgical treatment of hand deformities in hereditary dystrophic bullous epidermolysis]. / Hirursko lecenje deformacija sake kod hereditarne distrofijske bulozne epidermolize.

In the period 1996-2001 in the Clinic for Plastic Surgery and Burns of the Military Medical Academy, 18 patients. 12 male and 6 female, with hereditary dystrophic epidermolysis bullosa (HDEB) and hand deformities were surgically treated, to achieve the complete separation of fingers, correction of the thumb adduction contracture and flexion or extension contracture of finger joints. The period of wound healing on flat surfaces after surgery, and the period between two operations was estimated. The most common deformity was the flexion contractures of metacarpophalangeal (MP) joints (45%) and one or both interphalangeal (IP) joints (types A1, A2). In 20% of the hands MP joint was stretched with the flexion contracture in distal interphalangeal (DIP) or both IP joints (types B1, B2). In 35% of hands MP joint was in hyperextension with folded proximal interphalangeal (PIP) or both IP joints (C1 i C2). The adduction deformity of the thumb type 1, without the possibility of abduction, was present in 15%, type 2, when the thumb was placed above the palm in 60% and type 3, when the thumb was fused in the palm in 25%. Pseudosyndactyly of the first degree (till PIP joint) was found in 30% of hands, the second degree (till DIP joint) in 25%, and the third degree (the whole finger length) in 45% of hands. Fingers were completely separated and stretched surgically. The period of spontaneous healing was 15 days on the average. EBDC represents great medical and social problem that requires multidisciplinary approach of physicians of various specialties (surgeons, dermatologists, pediatrists, geneticists, nutritionists, physiatrists, ophthalmologists, dentists, ENT, as well as specially trained persons and families). The efficient specific systemic therapy aiming to increase the skin resistance to mechanical trauma does not exist yet, and should be developed in the field of gene therapy. The surgical correction of hand deformities, acrylate glove use in the longer post operative period combined with physiotherapy, the active use of hands, the protection of injuries and skin care are the measures which prolong the period between the recurrence of contractures.

[Microvascular free flaps and care of war injuries with tissue defects]. / Mikrovaskularni slobodni reznjevi u zbrinjavanju ratnih rana sa defektima tkiva.

BACKGROUND: War wounds caused by modern infantry weapons or explosive devices are very often associated with the defects of soft and bone tissue. According to their structure, tissue defects can be simple or complex. In accordance with war surgical doctrine, at the Clinic for Plastic Surgery and Burns of the Military Medical Academy, free flaps were used in the treatment of 108 patients with large tissue defects. With the aim of closing war wounds, covering deep structures, or making the preconditions for reconstruction of deep structures, free flaps were applied in primary, delayed, or secondary term. The main criteria for using free flaps were general condition of the wounded, extent, location, and structure of tissue defects. The aim was also to point out the advantages and disadvantages of the application of free flaps in the treatment of war wounds. METHODS: One hundred and eleven microvascular free flaps were applied, both simple and complex, for closing the war wounds with extensive tissue defects. The main criteria for the application of free flaps were: general condition of the wounded, size, localization, and structure of tissue defects. For the extensive defects of the tissue, as well as for severely contaminated wounds latissimus dorsi free flaps were used. For tissue defects of distal parts of the lower extremities, scapular free flaps were preferred. While using free tissue transfer for recompensation of bone defects, free vascularized fibular grafts were applied, and in skin and bone defects complex free osteoseptocutaneous fibular, free osteoseptocutaneous radial forearm, and free skin-bone scapular flaps were used. RESULTS: After free flap transfer 16 (14.4%) revisions were performed, and after 8 unsuccessful revisions another free flaps were utilized in 3 (37.5%) patients, and cross leg flaps in 5 (62.5%) patients. CONCLUSION: The treatment of war wounds with large tissue defects by the application of free microvascular flaps provided shorter wound-closing period, earlier beginning of physical therapy, as well as the treatment of great number of patients with the extensive tissue defects in the conditions of massive influx of the wounded.

[Management of war burns of the lower leg using free flaps]. / Mogucnost zbrinjavanja ratnih opekotina potkolenice slobodnim reznjevima.

Free flaps are used in the surgical treatment of burns for wound closure where the burn is too deep, and in case, when after necrotic tissue excision, the bones, tendons, nerves, and blood vessels remain bare. Covering of the exposed structures is commonly performed in the primary delayed, or in the secondary wound treatment. The possibilities of covering the defects of the lower leg with local flaps are limited. Free flaps are used when all the possibilities of the other reconstructive procedures have been exhausted. The defect of the soft tissue of the lower leg was covered with free flaps in the injured soldiers with deep burns, treated at the Clinic for Plastic Surgery and Burns, Military Medical Academy, Belgrade. In one patient the wound closing was performed immediately after excision of necrotic tissues, and in the other two in the secondary management. The application of free microvascular flaps enabled the closure of large post excision defects of the lower leg in one operation. Our experience in the treatment of these soldiers point to the possibility of coverage of the exposed deep structures with free flaps as early as possible.