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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 5 of 10

Figure 1. Approaches to triage and patient management following mass casualty incidents. ATLS: advanced trauma life support

The discussion is considerably more germane in resource constrained regions where rehabilitation services
and prosthetics are extremely costly and often unavailable. A review on land mine induced lower extremity
injuries in developing countries highlights poor post-amputation outcomes associated with a significant
[20]
inability to access rehabilitation, return to work, and provide for families . With post-earthquake
[21]
amputation rates around 6% , deployment of salvage teams helps curtail such significant societal losses.

This guides conversation towards the importance of limb salvage. Ideal extremity trauma reconstruction
[22]
aims to obtain soft-tissue coverage, restore appropriate form, and maintain or improve function . In the
acute to subacute setting of MCIs, the feasibility of reconstruction is challenged. As numerous patients
present with contamination and injuries to several body zones, a balance between otherwise reliable local
tissue rearrangements and their complex free flap alternatives must be achieved.

Following the Boston Bombings, our institution utilized both local and free flaps for extremity
reconstruction. Playing a fundamental role in early soft tissue closure, local flaps are associated with shorter
procedure times, reduced complexity, and are of similar tissue quality and color to that of the recipient
[23]
site . Based on a pedicle, local flaps offer considerable adaptability with tailored thinning and a rotational
advantage. Moreover, as depicted from experience following the 2015 Earthquake in Haiti, local flap coverage
can be performed in field hospitals lacking the infrastructure necessary for free flap microsurgery . With
[10]
a significant influx of patients, the use of local flaps effectively allows for durable soft tissue coverage in the
acute to subacute period providing an equitable distribution of services to patients.

With the high incidence of hand injuries following MCIs, there is particular utility in local reconstructive
flaps including V-Y advancement flaps for dorsal fingertip reconstruction, the dorsal metacarpal artery flap
[24]
for thumb reconstruction, and cross-finger transposition flaps . Local forearm and elbow reconstruction