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Crystal et al. Plast Aesthet Res 2019;6:1 I http://dx.doi.org/10.20517/2347-9264.2018.69 Page 3 of 10

The first patient presented with an open left fibula fracture, left medial and right posterior calf wounds, and a
left thigh wound. After debridement and washout, the fibula fracture was reduced, and tissue reconstruction
[7]
was performed with a local soleus muscle flap . A second patient presented with a partial left lower
extremity traumatic amputation, an open right tibia/fibula fracture, and several leg and buttock wounds. A
completion left below-the-knee amputation and several washouts with debridement were necessary. After
external fixation and negative pressure wound therapy, a free latissimus dorsi muscle flap and split thickness
[7]
skin graft were used for right lower extremity reconstruction . The third patient presented with an open left
tibia/fibula fracture and non-viable left foot. Completion amputation and negative pressure wound therapy
followed by revision amputation were performed. A local gastrocnemius flap with split thickness skin
[7]
grafting was required for closure of the complex amputation defect .
At our affiliate hospital, 13 patients required emergent surgery. Among those patients, 72 procedures would
[8]
be completed, of which a remarkable 37% were performed by plastic surgery . Moreover, nearly 50% of these
[8]
emergent surgery patients required free flaps for limb salvage . Among all receiving hospitals, 54 patients
underwent emergent surgery and 12 patients underwent definitive amputation for control of life-threatening
[6]
hemorrhage and/or severe, unsalvageable extremity wounds .
2015-2016 terror attacks in Ankara, Turkey
In a period of one year the capital city of Turkey, Ankara, was struck by two major terrorist attacks. On 10
Oct 2015, a suicide bomber detonated an explosive in Ankara’s central railway station. This was followed
on 13 Mar 2016 by a car bomb detonated during rush hour at Kızılay Square-Güvenpark. In total, there
were 434 casualties, 178 of whom would receive care at Ankara Numune Training and Research Hospital, a
[9]
tertiary health and trauma center within Ankara .
Of the casualties received, 28% sustained an upper extremity injury and 50% sustained a lower extremity
[9]
injury . A retrospective review was conducted on 34 victims who required surgical treatment by the plastic
[9]
surgery service at Ankara Numune Hospital . Of note, patients treated in the emergency department for
minor injuries and small primary closures were not included in this review. In total, one patient required
thumb replantation while an additional eight patients had hand surgery for phalynx fractures, flexor tendon
repairs, and peripheral nerve injuries. One presenting patient required a local trapezius muscle flap for a
shoulder soft tissue defect. Another required a free radial forearm fasciocutaneous flap for soft tissue trauma
to the medial foot. Lastly, a third patient presented with a Gustilo IIIB fracture requiring a free anterolateral
thigh fasciocutaneous flap for coverage of exposed tibia. Partial flap necrosis occurred, prompting salvage
[9]
treatment by means of a cross-leg flap .

Importantly, the authors highlight that the lack of plastic surgeons in their hospital trauma advisory council
and their delayed consultation following the incidents were barriers to providing services. Although no
amputations were reported in their cohort, the surgeons note that amputations were performed prior to
consultation.

2010 earthquake in Haiti
On January 12, 2010, a 7.0-magnitude earthquake struck the nation of Haiti. In an already resource
constrained nation, the humanitarian crisis which followed was of mass proportion. Part of the relief
[10]
experience was captured by a responding British orthoplastic envoy . Similar to experiences documented
[11]
from a 7.4-magnitude earthquake in Turkey , the predominant injury received by the surgical team were
[10]
extremity crush injuries .
In total, 348 operations were performed by the orthoplastic limb salvage team on 158 patients. The 73% of
procedures were of soft-tissue origin and performed by plastic surgeons, while 18% of procedures were of