TY - JOUR
AU - Rodriguez, Eduardo, D
AB - Abstract Introduction Ongoing combat operations in Iraq, Afghanistan, and other theaters have led to an increase in high energy craniomaxillofacial (CMF) wounds. These challenging injuries are typically associated with complex tissue deficiencies, evolving areas of necrosis, and bony comminution with bone and ballistic fragment sequestrum. Restoring form and function in these combat-sustained CMF injuries is challenging, and frequently requires local and distant tissue transfers. War injuries are different than the isolated trauma seen in the civilian sector. Donor sites are limited on patients with blast injuries and they may have preferences or functional reasons for the decisions to choose flaps from the available donor sites. Methods A case series of patients who sustained severe combat-related CMF injury and were treated at Walter Reed National Military Medical Center (WRNMMC) is presented. Our study was exempt from Institutional Review Board review, and appropriate written consent was obtained from all patients included in the study for the use of representative clinical images. Results Four patients treated by the CMF team at Walter Reed National Military Medical Center are presented. In this study, we highlight their surgical management by the CMF team at WRNMMC, detail their postoperative course, and illustrate the outcomes achieved using representative patient clinical images. We also supplement this case series demonstrating military approaches to complex CMF injuries with CMF reconstructive algorithms utilized by the senior author (EDR) in the management of civilian complex avulsive injuries of the upper, mid, and lower face are thoroughly reviewed. Conclusion While the epidemiology and characteristics of military CMF injuries have been well described, their management remains poorly defined and creates an opportunity for reconstructive principles proven in the civilian sector to be applied in the care of severely wounded service members. The War on Terror marks the first time that microsurgery has been used extensively to reconstruct combat sustained wounds of the CMF region. Our manuscript reviews various options to reconstruct these devastating CMF injuries and emphasizes the need for steady communication between the civilian and military surgical communities to establish the best care for these complex patients. CMF Trauma, CMF Reconstruction, Facial Trauma, Facial Reconstruction, Microsurgery INTRODUCTION On today’s battlefield, survival rates after combat related injury are greater than 90%.1 Ongoing combat operations in Iraq, Afghanistan, and other theaters have led to an increase in both craniomaxillofacial (CMF) and extremity wounds.2–6 Body armor has improved patient survival, but the head and extremities remain vulnerable to explosive devices and high velocity projectiles.7–10 While head and neck protection has become a priority for military research, it remains in early stages of development.11–14 Craniomaxillofacial injury may also be sustained by civilians in combat zones.15 These challenging injures are typically associated with complex tissue deficiencies, evolving area of necrosis, bony comminution with bone and ballistic fragment sequestrum,16 and frequently require free tissue transfer for reconstruction. The Global War on Terrorism (OIF/OEF) is the first major war where microsurgical reconstruction played a major role. In the military, acute trauma patient care is guided by the Clinical Practice Guidelines (CPG), however there is none for facial trauma.17 In the Joint Trauma System (JTS), management of life-threatening injuries and initial patient treatment are performed at the Role 1 and 2 medical treatment facilities.18 Initial care in the form of debridement and fracture fixation is then performed at Role 3 medical treatment facilities in theater within the first 24 hours.19 When the stable patient arrives at Role 4 or 5 facilities, usually within 24–72 hours (Supplementary Figure 1), definitive flap reconstruction can be undertaken.20 This is typically done in the United States at Walter Reed National Military Medical Center (WRNMMC) or Brooke Army Medical Center (BAMC). This expeditious transport allows for reconstructive surgeons to adhere to the established principles of maintaining skeletal structure and projection to prevent soft tissue contracture.16 Restoring form and function in CMF injuries is challenging, and requires local and distant tissue transfers with varying success,21–24 and may fall short in providing critical functions such as oral competence and eyelid function.20 Battlefield lessons have been successfully translated to the civilian medical sector, including the modern civilian trauma system, hemostatic agents, and REBOA.18,25–27 Similarly, the treatment of CMF trauma originated from the battlefields of both World Wars,28,29 and reconstructive techniques established a century ago by Sir Harold Gillies are still used today.30 Communication between the civilian and military surgeons to promote research and outcome analysis will enhance care in the future for these complex patients. OIF/OEF is the first time microsurgery has been used to reconstruct these complex CMF injuries, a capability that Gillies did not have. While the characteristics of military CMF injuries have been well described3–5,31 their management remains poorly defined,21,32 and creates an opportunity for reconstructive principles pioneered in the civilian sector to be applied in the care of severely wounded service members.33–35 In this study, we provide a case series of patients who sustained combat-related CMF injury and were treated at Walter Reed National Military Medical Center (WRNMMC) and review reconstructive algorithms utilized by the senior author (E.D.R.) in the management of complex CMF injuries. It is important to note that there are differences between the management of these patients and the senior author’s preferences. This serves to highlight the many ways to approach CMF reconstruction, and that there is not just one hard and fast treatment algorithm. Battlefield injuries are rarely isolated to the craniofacial structures. Often, significant extremity injuries are associated, limiting flap donor sites. Additionally the patients may have functional and personal motivations that restrict donor sites further. For this reason, algorithms are more complex as flap selection may become very individualized due to pattern of injury, donor site limitations, other reconstructive needs, and patient preference for donor site. It is critical to be familiar with all of the options as combinations of both traditional and microsurgical reconstructive techniques may be necessary. METHODS A review of four patients who underwent CMF reconstruction at Walter Reed was performed. Our study was exempt from WRNNMC Institutional Review Board, and appropriate patient written consent was obtained. It is important to note that the initial reconstruction of these patients occurred early, within the first 1–2 weeks. Additional reconstructive procedures occurred over the ensuing years due to the complex, evolving nature of these CMF injuries. Case Series Case 1 A 34-year-old male who sustained dismounted improvised explosive device injuries while on patrol in Iraq in 2005 resulting in penetrating intracranial injury, left traumatic globe injury, left cranio-orbital and midface fractures (Supplementary Figure 2). He underwent emergent exploration of orbital, cranial and neck wounds including orbital exenteration, craniectomy, and tracheostomy and was transferred to WRNMMC for definitive management. His facial fractures were addressed at WRNMMC and his hospital course was complicated by recurrent craniofacial infections. Seven months following his initial injury the patient underwent cranioplasty complicated by soft tissue breakdown, necessitating further reconstruction utilizing a right radial forearm free flap. The superior thyroid artery and vein were utilized as recipient vessels (Fig. 1). He had a late cranioplasty infection and is now 5 years out from tissue expansion and a dead-space free low profile cranioplasty, with a stable result. FIGURE 1. View largeDownload slide (A) Intraoperative photo of radial forearm free flap utilized for cranio-orbital soft tissue coverage; (B) Post-operative photo demonstrating cranio-orbital reconstruction utilizing radial forearm free flap. FIGURE 1. View largeDownload slide (A) Intraoperative photo of radial forearm free flap utilized for cranio-orbital soft tissue coverage; (B) Post-operative photo demonstrating cranio-orbital reconstruction utilizing radial forearm free flap. Case 2 A 26-year-old male soldier sustained cranio-orbital injury when a suicide bomber detonated in proximity. After stabilization, he was immediately transferred to WRNMMC for definitive management. His craniofacial injuries included traumatic right orbital exenteration, naso-orbitoethmoid (NOE) fractures with overlying soft tissue defect and injury to left eye (Supplementary Figure 3). Pericranial flaps were used for lining and periorbital reconstruction. A cranial bone graft was used for upper third nasal support. A radial forearm free flap was used for coverage. (Fig. 2). He subsequently underwent flap debulking on the right cheek, and scalp STSG for color match on the nose (Fig. 3). Early reconstruction was important to provide lining, support and coverage of the craniofacial structures, and avoid contraction of the lower 2/3 of the nose. FIGURE 2. View largeDownload slide (A) Pericranial flap for periorbital reconstruction; (B) 3D CT reconstruction of skeletal injury. (C) Cantilever bone graft for nasal reconstruction; (D) 3D CT of reconstruction of skeletal injury using cantilever bone graft. FIGURE 2. View largeDownload slide (A) Pericranial flap for periorbital reconstruction; (B) 3D CT reconstruction of skeletal injury. (C) Cantilever bone graft for nasal reconstruction; (D) 3D CT of reconstruction of skeletal injury using cantilever bone graft. FIGURE 3. View largeDownload slide (A) Radial forearm free flap utilized to reconstruct soft tissue defect. (B) Patient 2 with custom ocular prosthesis. The radial forearm flap was carefully excised/debulked serially to provide the optimum esthetic outcome. FIGURE 3. View largeDownload slide (A) Radial forearm free flap utilized to reconstruct soft tissue defect. (B) Patient 2 with custom ocular prosthesis. The radial forearm flap was carefully excised/debulked serially to provide the optimum esthetic outcome. Case 3 A 4-year-old girl was injured in a blast and has been subsequently cared for stateside. She sustained significant craniofacial injuries including the loss of her nose, eyes, periorbital tissue, and midface fractures. She underwent tracheostomy, bilateral enucleation, early reduction and internal fixation of midface fractures, and temporoparietal fascia flaps to her orbits bilaterally. Overseas, she also underwent a pedicled latissimus dorsi flap to cover exposed hardware, complicated by flap failure and donor site complications. Upon transitioning her care to the WRNMMC, she underwent hardware removal. She was initially managed with a nasal prosthesis and then elected for more definitive nasal reconstruction after growth, development and psychosocial wellness (Supplementary Figure 4). As part of her staged nasal reconstruction, she had a tissue expander placed and a cervicofacial advancement flap performed to remove the latissimus skin paddle for improved color match. At 8 years of age, a radial forearm flap was used for nasal lining and lower eyelid reconstruction (Fig. 4). This was followed by cartilage framework and external coverage using a paramedian forehead flap. (Fig. 5). The patient has resumed activities of daily living. (Supplementary Figure 5). Figure 4. View largeDownload slide (A) Radial forearm free flap prior to transfer to nose; (B) Intraoperative nasal lining reconstruction utilizing radial forearm free flap. Figure 4. View largeDownload slide (A) Radial forearm free flap prior to transfer to nose; (B) Intraoperative nasal lining reconstruction utilizing radial forearm free flap. FIGURE 5. View largeDownload slide (A) Paramedian forehead flap used to reconstruct nasal surface following reconstruction of cartilage skeleton; (B) Inset of paramedian forehead flap with nasal stents in place. FIGURE 5. View largeDownload slide (A) Paramedian forehead flap used to reconstruct nasal surface following reconstruction of cartilage skeleton; (B) Inset of paramedian forehead flap with nasal stents in place. Case 4 A 32-year-old male sustained significant blast-related injury to the lower third of the face resulting in skeletal and soft tissue deficits. A 1–2 centimeter segmental defect of the anterior portion of the mandible was notable. The skeletal defect was also associated with an overlying deficit of the lower lip. Following debridement of the lower lip and underlying mandibular defect, reconstruction was performed using a free radial forearm osteoseptocutaneous flap. (Fig. 6) This option was appropriate given the limited nature of the mandibular skeletal defect, whereas more extensive deficits would have warranted reconstruction using a fibula or deep circumflex iliac osteocutaneous flap. FIGURE 6. View largeDownload slide (A) Patient 4 post blast injury with defect of lower lip and mandible. (B) Patient 4 after reconstruction of lip and mandible with free radial forearm osteoseptocutaneous flap. (C) Free radial forearm osteoseptocutaneous flap. (Printed with permission and copyrights retained by Eduardo D. Rodriguez, MD, DDS). FIGURE 6. View largeDownload slide (A) Patient 4 post blast injury with defect of lower lip and mandible. (B) Patient 4 after reconstruction of lip and mandible with free radial forearm osteoseptocutaneous flap. (C) Free radial forearm osteoseptocutaneous flap. (Printed with permission and copyrights retained by Eduardo D. Rodriguez, MD, DDS). DISCUSSION Initial Considerations Early debridement of contaminated and devitalized tissue is critical prior to reconstruction to minimize complications, particularly infection and soft tissue envelope contraction.34,36 This can be performed every 48–72 hours until the wound bed is healthy and allows stabilization of critically ill patients prior to definitive reconstruction. Early skeletal fixation using spanning plates or external fixation should be performed to maintain the soft tissue envelope and prevent irreversible contraction. A definitive airway and feeding route via tracheostomy and gastrostomy tube placement should also be considered. C-spine clearance should be performed when possible, and computed tomography scan with contrast to outline vasculature for potential flap reconstruction may be considered. Upper Face Injury The upper one third of the face is a prominent area and requires meticulous reconstruction for optimal outcomes. Primary goals of reconstruction include preservation of hairline symmetry, brow symmetry, concealment of scars within hairlines or relaxed skin tension lines, and sparing of motor and sensory innervation.37 While the forehead was initially portrayed as a single esthetic unit38, different classification systems have described multiple subunits.39–41 The senior author has previously proposed a subunit-based classification.37 The esthetic subunits include central, paramedian, and lateral. The central subunit lies between the medial eyebrows from the glabella to the frontal hairline; the paramedian subunit extends laterally from the border of the central subunit to the lateral eyebrows, while the lateral subunit lies between the lateral eyebrows and the temporal hairline. Particular attention should be made to preserve eyebrow symmetry in the central and paramedian subunits. The less perceptible nature of the lateral subunit make it more forgiving, but injury to the frontal branch of the facial nerve should be avoided. Primary closure is appropriate for small defects, but increases the risk of distorting symmetry for larger wounds.39,42–44 Closure by secondary intention may also lead to distortion and contraction.39,41,45,46 The central subunit is characterized by limited skin laxity and less prominent relaxed tension lines, which make vertical primary closure more favorable, while horizontal primary closure in the other subunits is preferred. Split-thickness skin grafting (STSG) can successfully address superficial defects of variable sizes,38,39,45,47,48 but results in poor esthetic outcomes and flattens normal frontal anatomical contours with full-thickness defects.38,49–52 Scalp skin grafts can be used to provide a better color match.53 Tissue expansion may be considered in large defects given that it allows reconstruction with similar tissue color and texture,44,48 but is associated with complications including extrusion, infection, and contracture.41,47,52,54,55 Small to moderate full-thickness forehead defects may be treated with local flaps; while larger defects would require multiple local flaps, increasing the risk of wound complications, contracture, and loss of hairline and eyebrow symmetry.42,49,56 Free tissue transfer is therefore the most appropriate option for large full-thickness defects. Temple et al have previously suggested that the ideal size for free tissue transfer coverage is larger than 50 cm.2,57 Free flaps also allow future recreation of the hairline if needed with hair transplantation.58–60 While numerous microvascular reconstructive options are available, we recommend using the ulnar forearm free flap (UFFF) due to easy concealment of the donor site, a long vascular pedicle, and it’s less hirsute compared to other flaps.61 Radial forearm flaps (RFFF) are just as good at providing thin, pliable soft tissue. When bulkier options are required, the anterolateral thigh (ALT) flap is recommended. Affected subunits should be resected in their entirety with subsequent microvascular reconstruction for satisfactory esthetic outcomes. Our subunit classification system allows scar concealment and preserves forehead natural anatomical contours. Management of frontal sinus fractures and frontal sinus outflow (NFOT) tract injury have significantly evolved.62–76 Diagnostic indicators of injury include gross NFOT obstruction, frontal sinus floor fracture, or anterior table medial wall fracture on CT scan.62,77–79 Evaluation of concomitant facial fractures, neurologic status and cerebrospinal fluid leak are essential when determining treatment.63,65,69,80,81 We have relied on our 26 year experience in managing frontal sinus fractures to develop a statistically validated therapeutic algorithm based on anatomic fracture patterns as well as presence or absence of associated NFOT injury.62 Frontal sinus fractures not associated with NFOT injury may be managed conservatively with observation using serial clinical assessment and CT scans to monitor for development of mucocele. Fractures with obstructive NFOT injury are best addressed by cranialization or obliteration as previously described.62 Displaced frontal sinus fractures with associated non-obstructive NFOT injury should be treated with reconstruction of the anterior wall, with preservation of the outflow and mucosa.62 Endoscopy can be a useful approach to address and treat outflow complications.82,83 For patients with cranio-orbital injuries, it is critical to ensure there is no intracranial communication, especially when cranioplasty is performed.84 If the orbital bandeau needs reconstruction, we recommend the use of a fibula flap with flexor hallicus longus muscle.85,86 This provides buttress reconstruction as well as vascularized muscle to obliterate intracranial communication. Mid-Face Injury The anatomy of the maxilla and structures of the midface is complex, providing both structural support of the face, globe, and dentition along with delicate functionality such as blink. To reconstruct the buttresses of the midface, vascularized osteocutaneous flaps are preferred.34,87 Non-vascularized bone grafts undergo unpredictable absorption and are not suitable in scarred fields typically seen in high-energy trauma patients. Both vascularized fibula and iliac crest flaps can provide contour and a foundation for additional reconstruction with implants or orbital prosthesis.88 The osteocutaneous fibula free flap (OFFF) possesses a long pedicle and can be segmentalized for simultaneous recreation of the periorbital buttress and maxilla.35,89,90 This provides lower eyelid support, mitigates potential negative vector of the midface, restores the orbital floor and rim, and achieves symmetry in globe or prosthesis repositioning.87,88,90 For orbital exenteration, a vascularized soft tissue flap can obliterate dead space. Maxillary reconstruction should restore facial projection and contour, provide foundation for dental implant placement, and provide of mucosal lining to eliminate oro-nasal fistulas.34 Local flaps can be used for skin and mucosal lining if available. Non-vascularized bone grafts should be considered for small defects,91 while vascularized iliac crest bone grafts have the ideal dimensions for hemi-maxillary reconstruction. Vascularized OFFFs can be contoured to reconstruct the entire maxillary arch. Both skin and muscle can be procured with these two flaps to provide intra and extra-oral lining when necessary. Secondary distraction osteogenesis of the vascularized OFFF has been described to further improve the three-dimensional restoration of the maxilla in cases with cicatrical contraction.92 It is the preference of the senior author (EDR) to use either of these two flaps for vascularized bone reconstruction of the maxilla in patients with combat related injuries.34 Periorbital soft tissue coverage should be thin and pliable. The goal of reconstruction is to provide protection and support of the cornea and globe. This can be achieved through reconstruction of the eyelid itself or by providing support to a scarred and retracted eyelid.93–95 Many local flaps have been described to reconstruct the periorbital region, including the eyelid.93,96 Using techniques such as lid switch, Tenzel flaps, and composite grafting can reconstruct small eyelid defects. When local tissue options are not available, the senior author prefers the use of an UFFF to reconstruct periorbital soft tissue defects,94,95,97 while RFFFs, ALT flaps, and groin flaps are other options.95 Reconstruction of combat related nasal injury was pioneered by Gillies in World War I.30,98 Menick has since perfected nasal reconstruction using local flaps for lining and coverage and use of cartilage and bone from the ear or ribs to provide support.99,100 The goals of nasal reconstruction include restoration of esthetic morphology, mucosal lining, and air flow. Distant tissue can be transferred to provide lining and cover in the absence of local options. RFFF or UFFFs are the senior author’s preferences,35,101–104 as they provide thin, pliable tissue with a long vascular pedicle, and can be procured with a segment of bone to provide dorsal nasal support.103 Prelamination with cartilage for structural support has been described.101 When needed, they can be used to resurface and reconstruct the upper lip along with the nose. ALT flaps and RFFFs can also be used to provide nasal lining, while a paramedian forehead flap can be used for external coverage.105 Lower Face Injury For composite mandibular defects, restoring chewing, swallowing, speech, and oral competence in an esthetic manner is the primary goal of reconstruction.106,107 Limited defects can be managed with skeletal stabilization and bone grafting.108 Defects larger than 5 centimeters are best managed with vascularized free flaps using107,109 the fibula, iliac crest, radial forearm, or scapula.106,110,111 We have previously described a mandibular reconstruction algorithm that relies on the OFFF and iliac crest free flaps.107 These flaps have resulted in comparable positive outcomes.112–114 Contrary to previous classification schemes,110,111,115,116 our algorithm relies on simplifying the defect patterns. Unilateral dentoalveolar defects not crossing the midline are classified as type 1 if they do not extend beyond the mandibular angle and type 2 if they do. Bilateral dentoalveolar defects are classified as type 3 if no angular involvement is present and type 4 if it is. Defect types are also subclassified based on whether ipsilateral microvascular anastomosis is possible (A) or not (B), and whether the mandibular condyles are affected (C). The fibula or iliac crest free flap can be used for type 1 defects, or type 2 defects without condylar involvement. Type 2 defects with condylar involvement, type 3 defects, and type 4 defects are best managed with the OFFF. The iliac crest free flap has a contour106 and height108,117 that are comparable to those of the mandible, which improves oral competence and make it more suitable for dental implants. Its short vascular pedicle and absence of perforators prevent incorporation of osteotomies or anastomosis to contralateral vessels without grafts.118 The OFFF provides a long segment of bone with segmental perforators, which allow for multiple osteotomies and reconstruction of large defects, while its long vascular pedicle allows contralateral anastomosis.107,118 The RFFF can be used to construct osseous defects as well as soft tissue defects such as the lip, as we have shown in patient 4 (Fig. 6). Lip reconstruction should maintain oral competence, realign the lip elements, vermilion border, and achieve three-layer closure of the mucosa, muscle and skin in full-thickness defects.119 Defects involving less than 1/3 of the lip width may be closed primarily. Vermilion involvement may require sacrificing adjacent skin for optimal restoration of the lip elements.119 Extensive lip injuries will likely require free tissue transfer such as forearm and ALT flaps.119–121 Lip injuries that lie on the spectrum between these extremes may be reconstructed using various loco-regional flaps. Central and more medially located defects are better reconstructed using the Abbe flap, while the Estlander flap is more adequate for lateral defects.119,122–125 The Webster-Bernard and Karapandzic flap are useful for subtotal lip defects and allow medial advancement of the remaining lip segments. Importantly, potential resultant microstomia, as well as special attention to esthetic reconstruction of the commissures and philtrum should be kept in mind when reconstructing these defects. Limited cheek defects may be closed primarily whereas more extensive injuries may require tissue mobilization for optimal closure. Medial cheek defects are best managed with transposition or advancement flaps, including the V-Y advancement flap.126 Concealment of medial incisions in the melolabial crease should be performed when possible. The lateral cheek skin is more adherent to the underlying fascia as compared to that of the medial cheek, therefore limiting the usefulness of advancement flaps.126 Transposition and rotational flaps are therefore preferred for lateral cheek elements. Large defects not amenable to closure with local defects may eventually require free tissue transfer including among others, the cervicofacial and forearm flaps.127–132 Future Directions The limitations of conventional reconstruction following extensive CMF injury demands innovative reconstructive options for our wounded warriors. Facial transplantation (FT) is a potential reconstructive solution with encouraging outcomes.133,134 Surgical indications can be summarized as defects involving 60% or more of the surface area of the face, with irreparable damage or loss of the esthetic units of the central face, with or without loss of maxilla.135 The potential of FT to improve facial function, appearance, and quality of life must be balanced with the risks of immunosuppression. CONCLUSION The CMF region remains vulnerable in the warfighter. The devastating avulsive nature of these injuries requires prompt debridement along with highly specialized care by surgeons with expertise in CMF reconstruction ranging from local tissue rearrangement to distant free tissue transfer. It is important to note that most of these procedures are performed on our service men and women at Role 5 facilities. Severely injured patients may go on to have additional reconstructive needs. Multiple specialties including plastic surgery, oral surgery, otolaryngology, ophthalmology, psychiatry, physical therapy, and speech therapy are critical in providing the best outcome for these patients. These are long term relationships with our patients. Free tissue transfer plays an important role in complications, exposures, and evolving soft tissue needs over time. The four cases presented here are examples of possibilities for reconstruction, and we emphasize the neither the WRNMMC experience, nor the experience of the senior author are the only ways to tackle these complex problems. There is usually more than one way to reconstruct these complex defects, and we involve the patient with decision making. War injuries are different than the isolated trauma seen in the civilian sector. Donor sites are limited on patients with blast injuries and they may have preferences or functional reasons for the decisions to choose flaps from the available donor sites. Our manuscript reviews various options to reconstruct these devastating CMF injuries and emphasizes that there is a need for steady communication between the civilian and military surgical communities to promote research and outcome analysis to establish the best care for these complex patients. It is important to note that injury to the facial nerve may occur with these ballistic injuries, however this manuscript focuses on structural and functional reconstruction of bone and soft tissue. Facial nerve reconstruction is the subject of future studies and manuscripts. We hope this manuscript opens doors to future studies of facial trauma management, as to benefit both the military and civilian community. The creation of a military CMF trauma registry and long term case studies would be of great benefit. REFERENCES 1 Goldberg MS : Death and injury rates of U.S. military personnel in Iraq . Mil Med 2010 ; 175 ( 4 ): 220 – 226 . 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TI - Reconstructing the Face of War
JF - Military Medicine
DO - 10.1093/milmed/usz103
DA - 2019-07-01
UR - https://www.deepdyve.com/lp/oxford-university-press/reconstructing-the-face-of-war-9VAKfUwOv0
SP - e236
VL - 184
IS - 7-8
DP - DeepDyve
ER -