Plastic and Reconstructive Surgery

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Plastic & Reconstructive Surgery:
doi: 10.1097/PRS.0b013e3182a98054
Reconstructive: Special Topic

Why We Are Here: Early Reflections on the Role of Reconstructive Plastic Surgery in the 2013 Boston Marathon Bombings

Carty, Matthew J. M.D.; Caterson, Edward J. M.D., Ph.D.; Caterson, Stephanie A. M.D.; Chun, Yoon S. M.D.; Erdmann-Sager, Jessica M.D.; Hadad, Ivan M.D.; Halvorson, Eric G. M.D.; Orgill, Dennis P. M.D., Ph.D.; Sampson, Christian E. M.D.; Talbot, Simon G. M.D.; Theman, Todd M.D.; Eriksson, Elof M.D., Ph.D.

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Boston, Mass.

From the Division of Plastic Surgery, Department of Surgery, Brigham & Women’s Hospital, and Harvard Plastic Surgery Combined Residency Program.

Received for publication June 3, 2013; accepted July 1, 2013.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

Matthew J. Carty, M.D., BWH Division of Plastic Surgery at Faulkner Hospital, 1153 Centre Street, Jamaica Plain, Mass. 02130,

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Summary: The 2013 Boston Marathon bombings resulted in a large and unexpected influx of patients requiring acute multidisciplinary surgical care. The authors describe the surgical management experience of these patients at Brigham & Women’s Hospital and Brigham & Women’s Faulkner Hospital, with a particular focus on the important role played by reconstructive plastic surgery. The authors suggest that this experience illustrates the value of reconstructive plastic surgery in the treatment of these patients specifically and of trauma patients in general, and argue for the increasing importance of promoting our identity as a specialty.

At the time of this writing, more than a month has passed since the tragic 2013 Boston Marathon bombings. Having only recently completed the transition of the majority of patients into the rehabilitation phase of therapy, providers involved in the acute care of these patients are just now having the opportunity to reflect on the full scope of the event in the interest of determining what lessons can be learned. The task of collecting data from all participating hospitals in the greater metropolitan area is currently underway through a city-wide consortium effort, which is expected to take several months to complete. Once the data are compiled, it is anticipated that this effort will provide the most informative long-term perspectives regarding the bombings, including a detailed assessment of patient care outcomes.

In the absence of such collective data, we are left at present to make early assessments from fragmentary information that is largely institution-specific. Fortunately, the number of patients treated at each of the major Boston trauma centers is sufficient to render this effort a reasonable endeavor, with each institution having received at least 25 victims. Such assessments at this point must be made in a cautious fashion and presented with the intent of beginning, rather than concluding, discussion. In the current absence of city-wide data, we present a summary of our reconstructive experience at Brigham & Women’s Hospital and Brigham & Women’s Faulkner Hospital (Brigham & Women’s Hospital’s closest local affiliate institution).

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The most authoritative estimate of the total number of people injured due to the Boston Marathon bombings currently stands at 2641; of these, a total of 55 (21 percent) were treated at Brigham & Women’s Hospital and Brigham & Women’s Faulkner Hospital. Full evaluation of this cohort in the emergency department over the 2 hours following the event was notable for 20 operative lower extremity injuries, six operative upper extremity injuries, and three operative head/neck injuries; the remaining injuries were largely superficial fragmentation wounds that were amenable to bedside management (Table 1). Within 40 minutes of the bombing, the first victim was in the operating room, and was followed shortly by 15 additional surgical interventions over a total of 12 operating theaters. Operative stabilization of all patients was completed within 7 hours of the incident.

Table 1
Table 1
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As has been described in other reports,2 the low blast trajectory of the improvised explosive devices utilized by the perpetrators of the bombing preferentially resulted in complex injuries that included not only destruction of the bony architecture of the limbs but also substantial damage to the neurovascular structures and investing soft-tissue envelopes of the victims. In our institutions, early recognition of the composite nature of these injuries led to the immediate coordination of trauma surgery, orthopedic surgery, vascular surgery, and plastic surgery. The combined nature of this care was manifest from the arrival of the first patient in the emergency department, who was simultaneously evaluated by all four services; the subsequent management of all remaining operative patients was punctuated by the active circulation of more than 20 attending staff from these four disciplines through the active operating theaters. A debriefing held the morning after the event included a multidisciplinary discussion to define the reconstructive requirements of our institutional population and was followed by daily communications involving all four teams. Three days after the event, by which point all patients were deemed to be clinically stable, a formal multidisciplinary session was held to determine the optimal plan for each patient with regard to limb salvage versus amputation. Definitive management of all injured patients then proceeded expeditiously, including four free tissue transfers, 10 local advancement flaps, and 12 split-thickness skin grafts. Of the 20 operative lower extremity injuries treated, 18 (90 percent) were salvaged. Two (10 percent) required subsequent below-knee amputations, one due to nearly complete transtibial amputation of the limb at the bombing site requiring immediate limb sacrifice and the other due to extensive bone and nerve loss at the level of the ankle, undertaken after extensive discussions among all teams and with the patient following serial débridement. Final coverage of all patients was completed within a mean period of 5.7 days (range, 0 to 18 days), with an associated average length of stay of 12.3 days (range, 1 to 26 days) before discharge to rehabilitation (Table 1). No patient deaths occurred.

Throughout this process, reconstructive plastic surgery played a central role. Upon notification of the bombing, all available plastic surgery faculty and residents in our institutions reported to the emergency department and operating theaters to provide immediate assistance regarding acute management. Beyond closure of simple lacerations and superficial injuries evident in a subset of the victims, plastic surgery was immediately called upon to offer perspectives regarding the débridement of nonviable tissues, the evaluation of neurovascular structures, the extraction of foreign bodies, and the initial management of the plethora of complex open wounds. Plastic surgery was then responsible for the coordination of daily communications among the involved surgical services and was closely aligned with the orthopedic trauma service in the subsequent wound stabilization procedures that were required over the first several days after the bombing. All of the lower extremity coverage procedures were performed by plastic surgeons, including a coordinated effort by several faculty and staff to perform two free flaps and two complex débridement procedures simultaneously on four patients on the Saturday following the event. Of a total of 83 procedures performed on the bombing victims, 30 (37 percent) were performed by plastic surgeons, which was identical to the share performed by orthopedic surgery and nearly triple that of both trauma surgery and vascular surgery (Fig. 1). Of the 209 total patient days over which care was delivered, the largest share (97 days, 46 percent) was spent under the aegis of plastic surgery (Fig. 2) and 59 percent of all treated patients were discharged with plastic surgery as their primary service of record (Fig. 3).

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Fig. 1
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Fig. 2
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Fig. 3
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From a medical perspective, the principal lessons we are likely to garner from the Boston Marathon bombings will be related to how disaster care should be approached when there is an abundance—rather than a paucity—of resources available. In contrast to situations such as the 2004 Indian Ocean tsunami or the 2010 Haiti earthquake, the Marathon bombings were of a scope and scale that were more than evenly matched by the local healthcare system. The unprecedented actions of on-site first responders, the singular preparedness of the Emergency Medical Services triage system, and the proximity of no fewer than five world-class level I trauma centers to the site of the event conspired to enable the efficient and safe delivery of the vast majority of victims to well-equipped institutions in an extraordinarily timely fashion.3 Furthermore, each of the accepting medical centers had at its disposal more than ample resources to cover the unanticipated influx of acutely injured patients due not only to prior disaster scenario rehearsals but also to the fact that the event occurred at the time of most nursing staff shift changes and on the occasion of a local holiday (Patriot’s Day), when operative volumes tend to be lighter.4 Through a combination of predesigned preparedness and good luck, therefore, the Boston medical community was equipped to handle this event in a manner not witnessed in previous disaster situations.5–7

Part and parcel to this preparedness was an abundance of expertise and personnel available to provide acute surgical management. The depth and breadth of qualified surgical staff on site at our institutions resulted in a situation in which management choices could be made at the individual patient level rather than at the population level. What enabled this dynamic was not only the availability of appropriately experienced surgeons but also their willingness to communicate effectively to provide optimal care in the acute setting; at Brigham & Women’s Hospital and Brigham & Women’s Faulkner Hospital, this collaboration included trauma surgery, orthopedic surgery, vascular surgery, and—most germane to this report—plastic surgery. The net result of this communal approach was the efficient and coordinated surgical care of a large number of patients with a very high rate of limb salvage.

On a local level, our experience demonstrates the important contributions offered by plastic surgery in the multidisciplinary care of the bombing victims who received care at Brigham & Women’s Hospital and Brigham & Women’s Faulkner Hospital; more broadly, however, it speaks to the relevance of plastic surgery to trauma care, in general. Despite our expertise with complex wounds, familiarity with diverse reconstructive techniques, and knowledge of long-term functional outcomes, plastic surgeons are rarely considered to be central participants in the acute management of trauma victims, whether within the context of disaster scenarios or not. In addition, our contributions to the ongoing care of such patients, both in terms of operative management and general medical management, are frequently underappreciated. As demonstrated above, our participation in the care of our bombing victims involved an equivalent amount of surgical investment and the largest share of primary ownership of any of the involved services. Furthermore, our coordination of all parties enabled us to achieve the expeditious stabilization, fixation, and coverage of all injured patients in a fashion that speaks to the very essence of multidisciplinary care.

At Brigham & Women’s Hospital and Brigham & Women’s Faulkner Hospital, plastic surgery is fortunate to enjoy excellent relationships with other surgical services, with whom we frequently partner in complex reconstructive cases. This history undoubtedly contributed to an immediate expectation of collaboration in the context of the bombing victims, since it essentially represented a continuation of our standard method of practice. That our collective staffing resources were sufficient to treat each and every one of the bombing victims as an iteration of business as usual is, upon reflection, remarkable; difficult management decisions did not need to be made on the basis of finite resources. What reminded us of this fact in the heat of the moment on April 15, 2013, however, was an underlying foundation of interdisciplinary communication, trust, and teamwork. The importance of this collaborative dynamic is not to be minimized; indeed, early reports from other Boston institutions in which plastic surgery involvement in the care of bombing victims was either not enlisted or was done so at a late stage of management suggest substantially higher rates of limb sacrifice than was evidenced in our experience. In order to avoid drawing apocryphal conclusions, however, such information must be measured cautiously; for example, it is possible that these centers treated patients with injury patterns that were more extensive and/or severe than those witnessed at Brigham & Women’s Hospital and Brigham & Women’s Faulkner Hospital. In addition, it remains to be seen whether the long-term outcomes of those who underwent intensive limb salvage at our institution will fare better functionally than those who underwent more expeditious amputation.

At a higher level, early reflections on the relevance of reconstructive plastic surgery to the treatment of the victims of the Boston Marathon bombings lend credence to the developing notion of the “orthoplastic” management of extremity trauma patients.8 According to Levin, orthoplastic surgery refers to “the principles and practices of both specialties applied to a clinical problem either by a single provider, or teams of providers working in concert for the benefit of the patient”9; defined as such, the orthoplastic approach serves to expand the range of options available to a given patient by drawing on the collective resources of disparate disciplines.10 The value of applying this combined approach to the management of limb trauma has been described previously in the context of disaster scenarios, namely, the Haiti earthquake, in which particular reference was made to its positive impact on limb salvage.11 The degree to which this approach can be successfully executed in a resource-scarce environment such as Port Au Prince in 2010 should set a minimum benchmark against which we can gauge our performance in a resource-rich environment such as Boston in 2013. We anticipate that the outcomes that will eventually be reported by the consortium will speak to this issue.

In summary, a key lesson that has begun to emerge from the Boston Marathon experience is the critical role played by reconstructive plastic surgeons in both the acute and ongoing management of the bombing victims. The extent to which plastic surgery was involved in the collaborative operative management of these patients appears to have influenced the degree to which limb salvage was achieved, and speaks to the increasing importance of making plastic surgery a regular component of the trauma team. Many trauma teams that provide initial triage and treatment of patients facing limb salvage decisions do not have a plastic surgeon on the team; critical decisions about limb salvage and spare part utilization are therefore made without the benefit of fully informed reconstructive expertise. We believe that our experience demonstrates that what we have to offer as reconstructive plastic surgeons is both meaningful and beneficent. For patients to benefit maximally from our expertise, we must continue to promote our professional identity and capability in a manner that makes us as indispensable to the acute surgical care of complex trauma patients as our better-recognized colleagues are. We are the principal arbiters of reconstruction and restoration in the surgical sphere, and we must do all we can to be recognized as such. This is why we are here.

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1. Kotz D. After double checking records, injury toll from bombs reduced to 264. The Boston Globe. April 24, 2013:p. B3

2. Jangi S. Under the medical tent at the boston marathon. N Engl J Med. 2013;368:1953–1955.

3. Gawande A. Why Boston’s hospitals were ready. The New Yorker. April 17, 2013 Available at:

4. Kellerman AL, Peleg K. Lessons from Boston. N Engl J Med. 2013;368:1956–1957.

5. Biddinger PD, Baggish A, Harrington L, et al. Be prepared: The Boston Marathon and mass-casualty events. N Engl J Med. 2013;368:1958–1960.

6. Goralnick E, Gates J. We fight like we train. N Engl J Med. 2013;368:1960–1961.

7. Caterson EJ, Carty MJ, Weaver M, et al. Boston bombings: A surgical view of lessons learned from combat casualty care and the applicability to Boston’s terrorist attack. J Craniofac Surg. 2013;24:1061–1067.

8. Lerman OZ, Kovach SJ, Levin LS. The respective roles of plastic and orthopedic surgery in limb salvage. Plast Reconstr Surg. 2011;127(Suppl 1):215S–227S.

9. Levin LS. The reconstructive ladder: An orthoplastic approach. Orthop Clin North Am. 1993;24:393–409.

10. Nayagam S, Graham K, Pearse M, et al. Reconstructive surgery in limbs: The case for an orthoplastic approach. Ann Plast Surg. 2011;66:6–8.

11. Clover AJP, Rannan-Eliya A, Saeed W, et al. Experience of an orthoplastic limb salvage team after the Haiti earthquake: Analysis of caseload and early outcomes. Plast Reconstr Surg. 2011;127:2373–2380.

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