Plastic surgery and the military: Restoring form and function on the front line

Editor's note: The views expressed are those of the author and contributing authors, and do not reflect official policy or position of the U.S. Air Force, Army, Navy, Department of Defense or U.S. government. The author is not a member of the United States military nor does he have any financial disclosures or conflicts of interest.

Although the civilian sector produces the majority of plastic surgeons, another pathway into the field exists: the Medical Corps, a non-combat specialty section within each of the U.S. Army, Navy and Air Force – the three main branches of the U.S. Department of Defense.

Plastic surgeons have a long history of providing surgical support to service members and their families. In combat operations, aid is rendered through a series of roles in the casualty-evacuation chain. Operational team members occupy Role 1 and deliver lifesaving first aid at the point of injury. Role 2 delivers focused, acute care for up to 72 hours post-injury and can be enhanced by a forward surgical team (FST), which is equipped to perform damage-control procedures and traditionally defer more definitive interventions for the higher echelons of care. Role 3 is occupied by a combat support hospital with full surgical support, and Role 4 and 5 facilities are tertiary hospitals located outside (i.e., Landstuhl Regional Medical Center, Germany) or inside the United States (i.e., Walter Reed National Military Medical Center).

Plastic surgery's role evolved over time to meet the unique challenges of each conflict. In the American Civil War, surgical reconstruction occurred in the delayed setting – usually months after injury and removed from the front lines. Significant surgical advancements during World War I and II allowed for craniofacial and hand reconstruction to be performed closer to the point of injury. During the Korean and Vietnam wars, improvements in trauma care and casualty transport resulted in improved combat survival. Plastic surgeons began to see critically ill patients survive long enough for the management of more complex injuries. Continued advancements in field care and rapid evacuation during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) boosted the numbers of surviving personnel needing increasingly complex reconstruction in stateside military treatment facilities (MTFs).

Although warfare injury-related mortality is decreasing, combat injury patterns – particularly soft-tissue injuries to the head, neck and extremities – remain. Early plastic surgical consultation can help triage patients to limb salvage versus amputation, and a variety of reconstructive techniques, including free-tissue transfer, are now routinely employed. Decisions made by multidisciplinary limb-salvage teams closer to the point of injury can help maximize functional limb outcomes and can be conducted simultaneously with lifesaving decisions by other surgical teams. These decisions enlighten damage-control surgery during multiple casualty scenarios and emphasize the utility of having key decision-makers present in Role 2 and 3 positions.

Current trends in military medicine demonstrate a need for military plastic surgeons. Recent literature confirms that the proportion of reconstructive procedures in the military is increasing.5 Rapid assessment of limb salvage during damage-control surgery illustrates the need for plastic surgeons closer to the front lines, and decreased combat-related mortality rates also support the need for plastic surgeons on American soil. To better understand what it means to be a military plastic surgeon, we sought the insight of several plastic surgeons who served in the U.S. military at home and abroad.

PSR: Why did you decide to join the military?

Dr. Phillips: There's a strong desire to serve past and present service members (and their families) who protect our nation's freedoms. Military medicine also offers unique practice opportunities that are often different from those in the civilian sector. Military physicians are trained in fields such as undersea, flight, tactical and wilderness medicine, which allows for participation in combat operations and global humanitarian aid missions. There's also a desire to care for wounded warriors and treat the variety of complex injuries sustained during conflict. Military medicine provides early leadership opportunities within the Military Health System – such as commanding a forward surgical team or combat support hospitals, both of which are often in austere environments. Additional opportunities include serving in key hospital leadership roles and training the next generation of military physicians. Lastly, with the ever-growing cost of medical education, we're afforded the peace of mind to train without the compounding medical school debt that looms at the end of civilian-sector training.

Dr. Kumar: As a first-generation, proud citizen of the United States, I joined the military to serve and protect our country, patients, institutions and professions. I joined because my core ethos is one of service – and also to learn about systems leadership and how to engage in leadership roles early in my career. I felt as if I could serve in and out of uniform by being a voice of support to young plastic surgeons considering joining, and to those considering leaving. A life of service doesn't end when the uniform comes off. I wanted to learn how to walk headfirst into problems and take on the seemingly insurmountable while achieving great outcomes with, at times, only minimal resources. It's about learning how to take ownership of a situation and becoming confident in the fact that failure does not occur on my watch – no service member or colleague will suffer due to my lack of energy, commitment or will.

PSR: Can you describe the dynamic between entering the military and applying to medical school?

Dr. Phillips: For most, the process begins at the start of medical school. Most active-duty physicians attended the Uniformed Services University (USU) School of Medicine or attended medical school in the United States or Puerto Rico through the Armed Forces Health Professions Scholarship Program (HPSP).

The HPSP is offered by each of the three branches of the military to a variety of professional students across multiple disciplines such as medicine, dentistry, veterinary medicine, optometry, clinical psychology and nursing. After acceptance into an accredited medical school, candidates can apply through a local healthcare recruiting office. Those accepted to the HPSP are direct-commissioned as military officers into one of the respective military branches. HPSP scholarship recipients receive full tuition, fees and reimbursement for required books and equipment, in addition to a monthly living stipend throughout medical school. A signing bonus of $20,000 is also offered. In exchange for funding, a service duty "payback" obligation is incurred for the number of years of scholarship benefit or a three-year minimum, whichever is greater.

Certain residency or Fellowship training programs can also acquire additional active-duty service obligations. All commissioned officers are required to graduate Officers Basic Leadership Course, which, for HPSP students, is usually offered during the summer months between medical school Year 1-2. Throughout medical school, HPSP students are placed on inactive ready reserve (IRR) and cannot be called into service obligations until the completion of schooling.

PSR: How does status as a military physician affect transition into residency?

Dr. Phillips: After medical school, HPSP students are trained in ACGME-certified military residency programs at various MFTs or deferred to civilian residency programs. In the military, candidates enroll in a match process similar to civilian training programs. During residency, one remains on active duty; however, the "payback" doesn't begin until graduation from residency and involves working as an attending physician in an MTF; on deployment; or serving in one of the many unique job opportunities available to military physicians. Those unsure of whether they would like to commission may do so during residency via the Financial Assistance Program (FAP). Board-certified physicians who complete their training can apply to be a Direct Commissioned Officer and begin service upon commissioning.

PSR: How does status as a military physician affect the competitive edge as a subspecialty applicant?

Dr. Ortiz-Pomales: As a military physician, you feel welcomed most places you interview. In general, people understand that your background enabled you to handle seemingly insurmountable challenges in difficult settings; that you're no stranger to a shortage of resource availability; and that you've minimal support. Most PDs understand that you're durable, adaptable and mature – and that most of your learning curves will be shortened compared with your peers.

In the independent pathway, general surgery residency training is extremely helpful for the military plastic surgeon and amplifies the breadth of procedures you'll be able to perform after training. To apply for a subspecialty surgical Fellowship, one must first enroll in the military match. Successful completion lets you enroll in the civilian subspecialty surgical matches. This equates to one round of military "vetting" prior to enrolling in the civilian subspecialty match and is the manner by which the military ensures that the best-of-the-best are ready for subspecialty surgical training and have the full support of the military. During subspecialty training, you're protected from deployment to focus on education and only need to complete a physical readiness test.

PSR: What experiences helped prepare you for a plastic surgery career?

Dr. Criman: After general surgery residency, I deployed to Afghanistan as a part of a forward surgical team to provide medical support for U.S. and partner forces in the region. We worked out of a tent, had no dedicated O.R. lights and no lab capabilities. Our radiology department consisted of the X-ray that was owned and operated by our bomb-disposal specialist, and the O.R. table was a stretcher. This necessitated a certain creativity with respect to surgical problems, which is one of the fundamentals of plastic surgery.

On one occasion, an adolescent child was brought to our outpost for treatment. He had a proximal third lower-leg soft tissue defect with exposed tibia from a remote blast injury. Knowing the child would have to walk four kilometers along mountain paths for follow-up care, we opted for the least-invasive option. Using multiple, small relaxing incisions, we were able to close the wound primarily after debridement. The child healed well and without complication. The situation helped me begin to understand reconstructive concepts and left me with a deep appreciation for what I had yet to learn.

PSR: What influenced your decision to pursue plastic surgery?

Dr. Hwang: Before I joined the Medical Corps, I attended the United States Military Academy at West Point. After initially deciding on a career in general surgery, I spent a significant amount of time after 9/11 taking care of people with whom I graduated from West Point as they returned from combat. After a harrowing experience as a trauma and general surgeon, I decided to not only help people survive, but help them regain as much form and function as possible. A career as a military plastic surgeon allowed me to offer my services in this regard.

PSR: How has military plastic surgery complemented your career as a cleft and craniofacial surgeon?

Dr. Kumar: Both jobs are similar in many ways – first and foremost, they center on a core ethos of service. In both jobs, I spend every day caring for the sick, disenfranchised and poor. Developmental craniofacial abnormalities have been shown to disproportionately affect the indigent and least-resourced in society. Continuing to deliver state-of-the-art medical and surgical care to those who most need it is the epitome of military plastic surgery.

PSR: What are some advantages of a career as a military plastic surgeon?

Dr. Valerio: Serving as an active-duty member at Walter Reed during the height of war was a fortuitous experience. It was a busy time that required a significant amount of reconstructive surgery. I had the opportunity to participate in reconstructive endeavors from head-to-toe and dealt with a variety of unusual combat injuries. Aside from the advantages of a remarkable reconstructive experience, the military allows you to remain in active duty or transition into academia. I elected to pursue academia but still had the opportunity to serve in the reserves, through which I remained engaged in post-warfare reconstruction, military missions and deployment in Afghanistan.

As a captain, I gained invaluable leadership and mentorship opportunities that were occasionally operational and occasionally plastic surgery-related. I served as team leader for COVID-related missions and oversaw military ICU groups. I continue to serve on missions inside and outside the continental United States, and often MTFs will call-out to reserves for additional plastic surgical assistance in the event of an increased number of deployed surgeons. This career also affords opportunities for special outreach missions across the globe, including serving on the USNS Comfort. Global outreach missions allow plastic surgeons to serve in medical leadership positions to combat global medical crises, such as the Ebola epidemic.

PSR: Are field salvage improvements creating advanced reconstruction opportunities?

Dr. Kumar: The short answer is "yes." As point-of-conflict care and rapid evacuation systems improve, we see more patients survive with complex wounds in dire need of restorative plastic surgery. This fosters timely advances in limb salvage surgery, targeted muscle innervation, regenerative peripheral nerve interfaces and advanced prosthetics.

PSR: How do military plastic surgeons maintain their skills during non-conflict times?

Dr. Kumar: Military plastic surgeons can collaborate with civilian plastic surgeons through partnerships that enable them to remain active. Plastic surgeons often rotate at regional academic centers to stay up-to-date on advancements in plastic surgery.

PSR: What's your advice to someone considering a career as a military plastic surgeon?

Dr. Ortiz-Pomales: Be willing to be a "jack of all trades" and build a practice composed of many different niches. I'm chairman of our craniofacial program and also run the only DOD transgender team. On deployment during the Venezuelan crisis in 2019, I performed more than 250 procedures – half of which were cleft lip and palate-related. This career is an excellent choice for someone looking to be prepared for whatever comes their way.

Dr. Valerio: This a great career for exceptional professional and academic growth. Some of the greatest innovations in reconstructive surgery occurred during times in conflict. It's also a great opportunity to give back through service – not only through the military. There are opportunities to serve families of the military, veterans and wounded warriors, and there are civilian-military collaboratives. It's an especially rewarding opportunity for those also boarded in general surgery, as being dual-boarded maximizes one's ability to help those in need. Don't join the military based on someone else's experience, though. You need to assess the lay of the land, air and sea. Different times have different tempos, goals and missions, and non-conflict time is very different than wartime.

Dr. Hwang: This career affords a great opportunity to perform the full spectrum of plastic surgery while developing specific interests. Plenty of opportunities exist to explore cutting-edge advancements in warfare-related reconstruction, and the military is grateful to have its members cared for.

PSR: What does the future hold for military plastic surgeons?

Dr. Kumar: It's an exciting time for limb salvage and prosthetics. Free-tissue transfer, targeted muscle reinnervation and regenerative peripheral nerve interfaces changed the way we manage the traumatized limb. More than anything, we need to make sure we continue the service line. We need to encourage military plastic surgery careers as members transition back into civilian service. There's a continuous need for service and reservists as the need for plastic surgeons continues to grow. During OIF in Iraq, casualty evacuation times from point of conflict to the continental United States were as fast as 72 hours. Decreased combat mortality means an increased need for reconstruction – and after all, there's always surgical theatre.

In closing

Military plastic surgeons are critical members of the plastic surgical community. Unique opportunities range from frontline limb salvage to domestic, complex reconstruction at specialized U.S. military facilities, among many others. Significant advances have been and will continue to be made during conflict times – and military plastic surgeons serve as physician leaders in times of crisis, in surgical and non-surgical roles. Plastic Surgery Resident thanks these men and women for their service to the country and the field of plastic surgery.

Dr. Pontell is PGY-7 in the Department of Plastic & Reconstructive Surgery at Vanderbilt University Medical Center.