Military Surgeons Research Articles

Management Considerations for Unicompartmental Osteoarthritis in Athletic Populations: A Review of the Literature.

Unicompartmental osteoarthritis in the young athlete poses a challenge for both patients and providers. Coronal plane malalignment is frequently a concomitant finding that adds to the complexity of management. Military surgeons are presented unique challenges, in that they must consider optimal joint-preservation methods while returning patients to a high-demand occupational function. Management options range from lifestyle changes to surgical interventions. We present a concise review of the available literature on this subject, with a specific focus on indications and outcomes within the military and young athletic population.

An Old Defence Against New Infections: The Open-Air Factor and COVID-19.

Outdoors, the risks of transmission of COVID-19 and many other respiratory infections are low. Several environmental factors are known to reduce the viability of viruses and other infectious pathogens in the air. They include variations in temperature, relative humidity, solar ultraviolet radiation, and dilution effects. But one agent that reduces the viability of both viruses and bacteria outdoors, the germicidal open-air factor (OAF), has not been properly recognized for decades. This is despite robust evidence that the OAF can influence both the survival of airborne pathogens and the course of infections.The germicidal effects of outdoor air were widely exploited during the late 19th and early 20th centuries. Firstly, in the treatment of tuberculosis patients who underwent 'open-air therapy' in sanatoria; and secondly by military surgeons during the First World War. They used the same open-air regimen in specially designed hospital wards to disinfect and heal severe wounds among injured soldiers. It was also used on influenza patients during the 1918-19 pandemic. Later, in the 1950s, open-air disinfection and treatment of burns were proposed in the event of nuclear warfare. During the 1960s, the OAF briefly returned to prominence when biodefence scientists conducted experiments proving that open air has a potent germicidal effect. When this work ended in the 1970s, interest in the OAF again fell away, and it remains largely ignored.The COVID-19 pandemic has revived interest in understanding the transmission dynamics and survival of viruses in the air. The pandemic has also stimulated research in the science and practice of improved ventilation to control respiratory infections. Such work is incomplete without an appreciation of the inactivation of viruses and other pathogens by the OAF, but this needs further investigation as a matter of urgency. Research to better understand the conditions under which the OAF can be preserved indoors is urgently needed. We need to review building design with better regard to infection control and patient recovery. But we need to act without delay, as there is already sufficient evidence to show that public health generally would improve if more emphasis was placed on increased exposure to outdoor air.

Committee on Surgical Combat Casualty Care position statement on the use of single surgeon teams and invited commentaries.

Over the last 20 years of war, there has been an operational need for far forward surgical teams near the point of injury. Over time, the medical footprint of these teams has decreased and the utilization of mobile single surgeon teams (SSTs) by the Services has increased. The increased use of SSTs is because of a tactical mobility requirement and not because of proven noninferiority of clinical outcomes. Through an iterative process, the Committee on Surgical Combat Casualty Care (CoSCCC) reviewed the utilization of SSTs and developed an expert-opinion consensus statement addressing the risks of SST utilization and proposed mitigation strategies. A small triservice working group of surgeons with deployment experience, to include SST deployments, developed a statement regarding the risks and benefits of SST utilization. The draft statement was reviewed by a working group at the CoSCCC meeting November 2021 and further refined. This was followed by an extensive iterative review process, which was conducted to ensure that the intended messaging was clear to senior medical leaders and operational commanders. The final draft was voted on by the entire CoSCCC membership. To inform the civilian trauma community, commentaries were solicited from civilian trauma leaders to help put this practice into context and to further the discussion in both military and civilian trauma communities. After multiple revisions, the SST statement was finalized in January 2022 and distributed to the CoSCCC membership for a vote. Of 42 voting members, there were three nonconcur votes. The SST statement underwent further revisions to address CoSCCC voting membership comments. Statement commentaries from the President of the American Association for the Surgery for Trauma, the chair of the Committee on Trauma, the Medical Director of the Military Health System Strategic Partnership with the American College of Surgeons and a recently retired military surgeon we included to put this military relevant statement into a civilian context and further delineate the risks and benefits of including the trauma care paradigm in the Department of Defense (DoD) deployed trauma system. The use of SSTs has a role in the operational environment; however, operational commanders must understand the tradeoff between tactical mobility and clinical capabilities. As SST tactical mobility increases, the ability of teams to care for multiple casualty incidents or provide sustained clinical operations decreases. The SST position statement is a communication tool to inform operational commanders and military medical leaders on the use of these teams on current and future battlefields.

Ascertaining the Readiness of Military Orthopedic Surgeons: A Revision to the Knowledge, Skills, and Abilities Methodology.

Decay of military surgeons' critical wartime skills is a persistent and growing concern among leaders in the military health system (MHS). The Knowledge, Skills and Abilities (KSA) Clinical Readiness Program was developed to quantify the readiness of clinicians in the MHS; however, the utility of the data is questionable due to a lack of focus on the operative expeditionary skillset in the original methodology. A revised methodology emphasizing the most relevant to expeditionary orthopedic surgery procedures is described. All Current Procedural Terminology (CPT) codes included in the original KSA methodology were reviewed and, if appropriate, removed, or reassigned to more suitable categories. Category scores were weighted to better align with the most performed procedures in the deployed environment. All surgical cases and procedures performed from 2017-2019 in military treatment facilities by orthopedic surgeons were recorded in total and by MHS market. Cases were recorded for all military orthopedic surgeons who performed at least one KSA credit procedure during the study period. The 10 MHS markets with the greatest number of procedures were included in the analysis. The change in creditable KSA procedure codes and procedures performed from the original to revised methodology was determined for each KSA category and MHS market. Overall, 403 CPT codes were recategorized and 79 were deleted from the original KSA methodology. The deletions represented less than 4% of the original creditable CPT codes, with most being supply or injection codes. Three of the five most common expeditionary KSA categories increased in the number of creditable procedure codes. The impact of the revision on the MHS markets was mixed, but the overall volume of credited procedures decreased. The weighted scoring did not disproportionately affect the analyzed markets. The revised methodology is better aligned with the most common procedures in the most recent large-scale military engagements. The improved applicability of the KSA scoring to necessary CWS will allow military medical leaders to better determine the readiness opportunities available in the MHS.

Military-civilian partnerships and the clinical readiness mission: A preliminary study from the Military Health System and the American College of Surgeons.

The Blue Book , published in conjunction with the Military Health System Strategic Partnership with the American College of Surgeons, serves as a reference manual for institutions wishing to establish a military-civilian partnership (MCP). To evaluate the applicability of the criteria contained in the Blue Book , we created a survey to be distributed to MCP military surgeons and their civilian host champions. E-mail surveys were sent to MCP military surgeons and civilian host champions. Military surgeons were queried about basic demographic information and aspects of the MCP including type, duration of assignment, onboarding, malpractice coverage, and billing for services. We gathered information on the role of military surgeons at the MCP, workload information, and trauma cases. The civilian host champions survey focused on institutional activities including trauma surgical volume, clinical and educational opportunities for the military surgeons, and exposure to research. Military-civilian partnership military surgeons and civilian host champions were questioned on program attributes: administrative support, budget, and profile of the program within the institution. Ten MCP military surgeons and 7 host champions completed surveys. The majority of military surgeons were assigned to the MCP for a 3-year instructor role (90%), and most were trauma surgeons (80%). Clinical activities for the military surgeon were where 60% spent ≥13 weeks annually on trauma. Military surgeons identified host program support in academic growth, deployment preparation, and sense of value at the MCP as positive attributes. Civilian host champions unanimously reported that exposure to research, opportunities to lead trauma teams, dedicated intensive care unit time, and patient volume were positive program attributes. This preliminary survey demonstrates that the criteria put forth in the Blue Book align with experiences of MCP military surgeons and host champions. Continued development of this survey and others like it may be useful in the MCP program selection and evaluation process. Therapeutic/care management; Level V.

Kirsten A. Greer. Red Coats and Wild Birds: How Military Ornithologists and Migrant Birds Shaped Empire

In Red Coats and Wild Birds, Kirsten Greer examines the motivations, practices, and consequences—for science, for empire, for masculinity—of nineteenth-century officer-ornithologists in the British army. Tracing the migratory paths of bird-watching lieutenants, ordnance officers, and military surgeons from their training grounds in the United Kingdom, to imperial way-stations in the Mediterranean (Malta and Gibraltar), to further-flung corners of the Empire (Crimea, New Brunswick, Nova Scotia, Tunisia, India), and back, Greer elucidates how the study of ornithology centered both the self-fashioning of British military masculinity and the production of geographical knowledge of the British Empire. The connection between the study of birds and military training, combat, and careering may not be immediately apparent to a modern reader, but ornithology constitutes a long and venerable tradition in the British military. By the nineteenth century—Greer’s period of study—participants had amassed an impressive “avian imperial archive” (12, 21) composed of diaries, journals, notes,...

Commentary: Standard of Care During a Crisis: What Should a Surgeon Know (and Do)?

Commentary: Standard of Care During a Crisis: What Should a Surgeon Know (and Do)?

Billing and Coding Education and Knowledge Among Military Orthopaedic Surgeons

Objectives: The purpose of this study is to evaluate the current level of billing and coding knowledge among resident and staff military orthopaedic surgeons. Design: Prospective survey, training, and assessment. Setting: Academic Military Level 1 Trauma Center. Intervention: Voluntary, anonymous survey relating to practice setting, billing, and coding practices, type of residency training and prior education on the subject. A quiz consisting of 23 questions to assess billing and coding knowledge. Main outcome measurement: Survey results and quiz scores. Results and conclusions: We had 68 responses comprised of 23 residents and 45 staff orthopaedic surgeons. Among residents, 86.14% (20/23) reported that they code encounters yet only 17.39% (4/23) responded that they have had formal training on billing and coding. 91.30% (21/23) felt that this topic should be taught in residency training. Among staff surgeons, 93.33% (42/45) code their own encounters and 42.22% (19/45) reported formal training on billing and coding. 93.33% (42/45) of staff felt that billing and coding should be taught in residency. The average quiz scores among residents and staff were 43.48% and 58.36%, respectively (p<0.0001). Scores among those with prior training in billing and coding were significantly higher overall (p= 0.033). Among staff there was no significant differences in scores related to years of experience, residency type, working with residents, years remaining in the military or participation in off-duty employment. Conclusion: There remains a paucity of formal training on billing and coding among military orthopaedic surgeons and this problem is not unique to military orthopaedic residency training programs. Those with formal training in billing and coding performed significantly better than those without, indicating that formal billing and coding training as part of graduate medical education may be effective in improving billing and coding knowledge among military orthopaedic surgeons. Level of Evidence: IV; survey Keywords: Billing, Coding, Medical education, Practice management.

The 2020 Pandemics: Lessons Learned in Academic Surgery and Beyond.

2020 was a significant year because of the occurrence of two simultaneous public health crises: the coronavirus pandemic and the public health crisis of racism brought into the spotlight by the murder of George Floyd. The coronavirus pandemic has affected all aspects of health care, particularly the delivery of surgical care, surgical education, and academic productivity. The concomitant public health crisis of racism and health inequality during the viral pandemic highlighted opportunities for action to address gaps in surgical care and the delivery of public health services. At the 2021 Academic Surgical Congress Hot Topics session on flexibility and leadership, we also explored how our military surgeon colleagues can provide guidance in leadership during times of crisis. The following is a summary of the issues discussed during the session and reflections on the important lessons learned in academic surgery over the past year.

Establishment of a combat damage control surgery training platform for explosive combined thoraco-abdominal injuries

PurposeIt is challenging to prepare military surgeons with the skills of combat damage control surgery (CDCS). The current study aimed to establish a damage control surgery (DCS) training platform for explosive combined thoraco-abdominal injuries. MethodsThe training platform established in this study consisted of 3 main components: (1) A 50 m × 50 m square yard was constructed as the explosion site. Safety was assessed through cameras. (2) Sixteen pigs were injured by an explosion of trinitrotoluene attached with steel balls and were randomly divided into the DCS group (accepted DCS) and the control group (have not accepted DCS). The mortality rate was observed. (3) The literature was reviewed to identify the key factors for assessing CDCS, and testing standards for CDCS were then established. Expert questionnaires were employed to evaluate the scientificity and feasibility of the testing standards. Then, a 5-day training course with incorporated tests was used to test the efficacy of the established platform. In total, 30 teams attended the first training course. The scores that the trainees received before and after the training were compared. SPSS 11.0 was employed to analyze the results. ResultsThe high-speed video playback confirmed the safety of the explosion site as no explosion fragments projected beyond the wall. No pig died within 24 h when DCS was performed, while 7 pigs died in the control group. After a literature review, assessment criteria for CDCS were established that had a total score of 100 points and had 4 major parts: leadership and team cooperation, resuscitation, surgical procedure, and final outcome. Expert questionnaire results showed that the scientific score was 8.6 ± 1.25, and the feasibility score was 8.74 ± 1.19. When compared with the basic level, the trainees’ score improved significantly after training. ConclusionThe platform established in this study was useful for CDCS training.

Letter in reply regarding "Clinical utilization of deployed military surgeons".

Letter in reply regarding "Clinical utilization of deployed military surgeons".

Letter regarding "Clinical utilization of deployed military surgeons".

Letter regarding "Clinical utilization of deployed military surgeons".

Upper-Extremity Vascular Exposures for Trauma: Comparative Performance Outcomes for General Surgeons and Orthopedic Surgeons.

As combat-related trauma decreases, there remains an increasing need to maintain the ability to care for trauma victims from other casualty events around the world (e.g., terrorism, natural disasters, and infrastructure failures). During these events, military surgeons often work closely with their civilian counterparts, often in austere and expeditionary contexts. In these environments, the primary aim of the surgical team is to implement damage control principles to avert blood loss, optimize oxygenation, and improve survival. Upper-extremity vascular injuries are associated with high rates of morbidity and mortality resulting from exsanguination and ischemic complications; however, fatalities may be avoided if hemorrhage is rapidly controlled. In austere contexts, deployed surgical teams typically include one general surgeon and one orthopedic surgeon, neither of which have acquired the expertise to manage these vascular injuries. The purpose of this study was to examine the baseline capabilities of general surgeons and orthopedic surgeons to surgically expose and control axillary and brachial arteries and to determine if the abilities of both groups could be increased through a focused cadaver-based training intervention. This study received IRB approval at our institution. Study methods included the use of cadavers for baseline assessment of procedural capabilities to expose and control axillary and brachial vessels, followed by 1:1 procedural training and posttraining re-assessment of procedural capabilities. Inferential analyses included ANOVA/MANOVA for within- and between-group effects (P < .05). Effect sizes were calculated using Cohen's d. Study outcomes demonstrated significant differences between the baseline performance abilities of the two groups, with general surgeons outperforming orthopedic surgeons. Before training, neither group reached performance benchmarks for overall or critical procedural abilities in exposing axillary and brachial vessels. Training led to increased abilities for both groups. There were statistically significant gains for overall procedural abilities, as well as for critical procedural elements that are directly associated with morbidity and mortality. These outcomes were consistent for both general and orthopedic surgeons. Effect sizes ranged between medium (general surgeons) and very large (orthopedic surgeons). There was a baseline capability gap for both general surgeons and orthopedic surgeons to surgically expose and control the axillary and brachial vessels. Outcomes from the course suggest that the methodology facilitates the acquisition of accurate and independent vascular procedural capabilities in the management of upper-extremity trauma injuries. The impact of this training for surgeons situated in expeditionary or remote contexts has direct relevance for caring for victims of extremity trauma. These outcomes underscore the need to train all surgeons serving in rural, remote, expeditionary, combat, or global health contexts to be able to competently manage extremity trauma and concurrent vascular injuries to increase the quality of care in those settings.

Impact of Civilian Patient Care on Major Amputation Case Volume in the Military Health System.

Sustaining critical wartime skills (CWS) during interwar periods is a recurrent and ongoing challenge for military surgeons. Amputation surgery for major extremity trauma is exceptionally common in wartime, so maintenance of surgical skills is necessary. This study was designed to examine the volume and distribution of amputation surgery performed in the military health system (MHS). All major amputations performed in military treatment facilities (MTF) for calendar years 2017-2019 were identified by current procedural terminology (CPT) codes. The date of surgery, operating surgeon National Provider Identifier, CPT code(s), amputation etiology (traumatic versus nontraumatic), and beneficiary status (military or civilian) were recorded for each surgical case. One thousand one hundred and eighty-four major amputations at 16 of the 49 military's inpatient facilities were identified, with two MTFs accounting for 46% (548/1,184) of the total. Six MTFs performed 120 major amputations for the treatment of acute traumatic injuries. Seventy-three percent (87/120) of traumatic amputations were performed at MTF1, with the majority of patients (86%; 75/87) being civilians emergently transported there after injury. Orthopedic and vascular surgeons performed 78% of major amputations, but only 9.7% (152/1,570) of all military surgeons performed any major amputation, with only 3% (52) involved in amputations for trauma. Nearly all (87%; 26/30) of the orthopedic surgeons at MTF1 performed major amputations, including those for trauma. This study highlights the importance of civilian patient care to increase major amputation surgical case volume and complexity to sustain critical wartime skills. The preservation and strategic expansion of effective military-civilian partnerships is essential for sustaining the knowledge and skills for optimal combat casualty care.

Military surgeon and professor of anatomy V.A. Pavlenko (to the 90-th anniversary of the department of military surgery)

Military surgeon and professor of anatomy V.A. Pavlenko (to the 90-th anniversary of the department of military surgery)

THE HISTORY OF DENTAL MEDICINE IN OSIJEK.

Throughout history, Osijek and Slavonia were parts of numerous empires and states. In this paper, the authors depict dental health care of the inhabitants of Osijek and Slavonia throughout their history, since the ancient prehistoric times when dental medicine and medicine in general were 'in the hands' of gods and medicine men, throughout the period of the Roman Empire and Middle Ages, as well as the Turkish sovereignty, all the way to the modern era when Osijek and Slavonia became part of the Austrian Empire and many novelties were introduced in the society, among other things, and for those times, modern procedures of medicine and dental protection. Those were the true beginnings of medicine and dental protection. The authors illustrate the work of various 'dentists' who worked in Osijek, from military and town surgeons, barbers, and especially the work of doctors that needed to have formal school and specialist education after the reforms implemented in the 19th century. Thanks to the reforms of the Austrian, and later the Austrian-Hungarian authorities, the practice and work of people who were allowed to perform dental procedures started being regulated, prices were established, and punishments introduced for those who performed dental procedures without having the proper qualifications.

Surgery without Sufficient Indications: an Update from Russia

This review is an update and continuation of preceding papers on invasive procedures applied in Russia with questionable clinical indications. Certain methods have been applied according to instructions by healthcare authorities and publication of leading specialists, facilitated by lacking professional autonomy. Examples are discussed here and in preceding papers: the overuse of Halsted and Patey mastectomy, preventive electrocoagulation of cervical ectropions without cytotological examination, gastrectomy for peptic ulcers, thoracic and abdominal surgery for bronchial asthma and diabetes mellitus, overuse of surgery in tuberculosis and other pulmonary conditions, overuse of bronchoscopy e.g. in conscripts with supposed pneumonia. Among mechanisms contributing to the persistence of suboptimal methods has been the autocratic or military managerial style discouraging criticism and polemics. Other attributes of this style are the paternalistic approach to patients and insufficient adherence to the principle of informed consent. Some invasive procedures with questionable indications were advocated by first generation military surgeons. Personnel training could have been one of the motives. Note that military and medical ethics are not the same. The comparatively short life expectancy in Russia is a strategic advantage as it necessitates less healthcare investments and pensions. Actually, Russia needs foreign help in the matter of healthcare. In view of the current international tensions, the cooperation has been partly interrupted. Obstacles to the import of medical products have adverse consequences. Under these circumstances, the purpose of this article was to remind that, performing a surgical or another invasive procedure, the risk-to-benefit ratio must be kept as low as possible. Insufficient coordination of medical studies and partial isolation from the international scientific community can result in parallelism in research, unnecessary experimentation, and application of invasive methods without sufficient indications.

EXPERIMENTAL MODELING OF A RESIDUAL WOUND CAVITY ON A BALISTIC PLASTICINE USING CONVENTIONAL AND HOLLOW POINT BULLETS

Relevance. Local armed conflicts of recent decades around the world are characterized by the use of hollow point (HP) bullets, which is another challenge for military surgeons. This confirms the importance for scientific research, in particular, experimental, aimed at studying the ballistic properties of various types of ammunition and the characteristics of the injuries caused by them in the wounded people. Simulation of a gunshot wound canal is an integral stage in the study of the gunshot wounds formation mechanism and is the subject of research in wound ballistics.&#x0D; Objective of the work is to develop an experimental model for ballistic imitation of the plastic deformation of biological tissues caused by the action of HP and non-HP bullets.&#x0D; Materials and methods. The studies were carried out on 40 blocks of ballistic plasticine, in each of which one shot was fired from an AKS-74 assault rifle and a ZBROYAR Z-10 carbine. Depending on the type of ammunition, the blocks of ballistic plasticine were divided into 4 groups: group I - 10 blocks, into which shots were made with non-HP military cartridges 5.45 mm with "PS" bullets with a steel core "7N6"; Group II (10 blocks) - 5.45x39 mm cartridges with V-Max HP bullets; group ІІІ (10 blocks) - with cartridges 7.62x39 mm; group IV (10 blocks) - cartridges 7.62x39 mm with HP bullets of the "SP" type.&#x0D; Results. It was found that when using non-HP bullets, the outer area of ​​the inlet ball hole correlates with the projectile caliber (1.6 times more than when using 7.62 mm bullets). For HP bullets, the caliber of the projectile does not significantly affect the area of ​​the entrance opening (P &lt;0.05). The expanding properties of the bullet significantly increase the area of ​​the bullet hole by 14.87-31.2 times compared to non-HP ammunition. An increase in the caliber of non-HP bullets leads to a significant increase in the area of ​​the sagittal section of the residual wound cavity by 1.59-2.03 times; The expanding properties of bullets of different calibers have a different effect on the volume of the residual wound cavity: for 5.45 mm bullets, the residual wound cavity increases 1.49 times, for 7.62 mm bullets it decreases 1.65 times.&#x0D; Conclusions. The type of small arms, the caliber of the cartridge, its expanding properties affect the spatial configuration of the main ballistic indicators arising in the proposed model of plastic deformation of soft tissues. The use of HP bullets leads to the formation of a larger volume of irreversible damage due to plastic deformation in comparison with non-HP analogs.

Associated projectile inferior vena cava wound with subsequent pulmonary artery missile embolization: a case report and literature review

A rare and unpredictable complication of firearm and missile injuries is projectile embolism. With only a few cases described in the literature, bullet embolism may become a diagnostic challenge for emergency physicians and military surgeons. Bullet embolization is a rare phenomenon, but the complications can be devastating. Case presentation. A 34‑year‑old man sustained a severe complex abdominoskeletal mine‑blast injury with damage to the hollow organs (duodenum and transverse colon), inferior vena cava and both low extremities. The internal hemorrhage was stopped by phleborrhaphy. The wounds of the duodenum and large intestine were sutured, and gunshot fractures of both anticnemions were stabilized by extrafocal osteosynthesis. The whole‑body CT showed that there was a projectile embolus into the branch of the right mid‑lobe pulmonary artery. No clinical manifestations of pulmonary artery embolism were observed in the patient. After surgery, he developed multiple necrosis and transverse colon perforations that resulted in fecal peritonitis. The suture line leakage that caused the formation of a duodenal fistula and postoperative wound infection were also detected. The complications were managed by multiple reoperations. The attempts of endovascular bullet extraction weren’t undertaken due to severe concomitant injuries, complications and asymptomatic clinical course of pulmonary artery projectile embolism. Open surgery retrieval of the embolus was successfully performed on the 80th day after injury. The patient was discharged from the hospital in good condition on the 168th day after the missile wound. Conclusions. Patients with missile wounds and no exit gunshot perforation should be examined using the whole‑body CT for determining possible migration of a projectile with the blood flow. Patients with asymptomatic pulmonary artery embolism should be managed nonoperatively. In case of symptomatic pulmonary artery projectile embolism, it is reasonable to consider the possibility of open thoracic surgery.

The Air Force Visiting Surgeon Program: Development, Outcomes, and Future Application.

Active duty service members and their families have limited access to subspecialty surgical care when assigned OCONUS. To address this issue, the Air Force Visiting Surgeon Program (VSP) was created to push subspecialty care to these locations. Visiting Surgeon Program was accomplished using temporary duty (TDY) orders. We conducted this 12-year review, 2009-2021, of the program to assess objective measures of impact, identify key lessons learned, and consider the program's future. In 2009, the senior author, Col Latham, performed a cost analysis of plastic surgery care provided at OCONUS installations and found that TRICARE Overseas often paid rates substantially higher than a TDY assignment for a single procedure. To improve beneficiaries' access to care while providing a cost savings to the health care system, 2-week plastic surgery missions were proposed to interested OCONUS military treatment facilities (MTFs). Ultimately, four sites selected to host the program in Alaska, Italy, England, and Japan. These sites were selected based on patient volumes, operating room capacity, and local command and surgeon support. By 2015, the Air Force formalized the program via Air Force Instruction 44-102 which outlined roles and responsibilities of MTF Commanders; established points of contact; and instituted key safety measures. To date, 58 missions have been completed by 21 surgeons through the VSP at Aviano Air Base (Italy; 24.1%), Joint Base Elmendorf-Richardson (Alaska; 31.0%), Royal Air Force Lakenheath (England; 27.6%), and Yokota Air Base (Japan; 17.2%). While primarily an Air Force program, 17% (10/58) of missions were supported Army or Navy surgeons. Overall, 2,000 patient consultations and 865 surgical cases were performed avoiding $6.7 million in cost. In addition to direct beneficiary care, the VSP also contributed to the participating surgeon and host surgical teams mission readiness. The VSP provides a template to make select subspecialty surgical care available in a cost-effective manner across the military health system, while also providing a model for the forward deployment of military plastic surgeons and triservice collaboration.