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Juan Cruz, a former Defense Department accountant, was burned over 50 percent of his body when terrorists crashed an airliner into the Pentagon on Sept 11, 2001.

"All I remember is that I was burning. My clothes were burning, and there was smoke all around," said Cruz, 57.

Since then, he has been through 40 surgical procedures, two cornea transplants and major facial reconstruction. He has had to give up driving because his vision is so clouded.

But Cruz, whose face was reconstructed at the Johns Hopkins Bayview Medical Center, represents a patient that plastic surgeons are seeing more often these days: the kind who wouldn't have survived years ago.

As military surgeons, hospital emergency departments and urban trauma centers improve survival rates for victims critically injured in fires and accidents and on battlefields, their patients are increasingly winding up in the care of specialists whose domain has long been associated with the tummy tuck and the nose job.

"There's no question more people are surviving, and it's creating a whole new set of challenges," said Dr. Paul Cederna, a plastic surgeon from the University of Michigan Health Systems, who joined 6,000 colleagues in Baltimore this week for the American Society of Plastic Surgeons' annual convention.

At the meeting, Cederna said physicians still need better ways to connect nerve endings with prosthetic devices for better control. But advances in microsurgery are enabling them to reattach blood vessels - about the size of human hairs - and move tissues from one body part to another, such as from one leg bone to another, with more precision than ever.

"It's work done in pretty small areas, and it's very tricky," Cederna said.

Among the challenges remaining are finding better ways to treat patients like Cruz, who face long and complex recoveries. "The doctors have said I was alive because of all the different techniques they have now. I also like to think it's because I was in good shape," said Cruz, who does push-ups and runs up to two miles a few times a week.

At the American Society of Plastic Surgical Nurses' convention, held concurrently here, Cruz's doctor described his technique for restoring facial features on such critically burned patients.

"For someone to get facial burns, it's usually a case where the injuries are really extensive. In a major fire, your first instinct is to cover your face," said Dr. Robert J. Spence, director of burn reconstruction at the Johns Hopkins Burn Center.

To restore Cruz's face, Spence first created new skin by implanting a balloonlike sac in his shoulder and injecting it with saline once a week for about three months. The injections allowed Cruz to produce more skin - the way a pregnant woman produces more skin as her pregnancy progresses.

Such balloonlike "tissue expanders" have been used for decades to treat mastectomy patients, Spence said. Once the skin expands, Spence cuts into it and creates a flap that he uses to cover damaged areas of the patient's face.

Traditional skin grafts generally work well, but the flap technique means transferring tissue with blood flowing through it, so that there is less chance of changes in skin color and texture, as sometimes occur with grafts, according to Spence and other experts.

"It's generally been received very well," said Dr. Joel J. Feldman, a professor at Harvard Medical School who uses the same technique with facial wounds in Cambridge, Mass.

To calculate someone's chances of surviving burn injuries, experts used to add the patient's age to the percentage of his body covered by burns. Together, they represented the patient's risk of mortality, Cederna said. So a 50-year-old patient burned over 40 percent of his body was generally estimated to have a 90 percent chance of dying.

But that's no longer true. "What's a survivable burn now is different than it was 10 or 20 years ago," Cederna said.

The same applies to other trauma victims. "We have more of all kinds of survivors," said Dr. Eduardo Rodriguez, chief of plastic reconstructive and maxillofacial surgery at the Maryland Shock Trauma Center.

A key at the trauma center is performing reconstructive surgery soon after the injuries occur, before broken bones knit improperly, Rodriguez said.

"We're treating patients earlier, and the sooner we can treat them, the better things go for them," he said.

In the Persian Gulf, 95 percent of the soldiers and Marines wounded who make it to a combat support hospital survive - many with injuries that years ago might have killed them, said Lt. Col. Barry M. Martin, a plastic surgeon at the Walter Reed Army Medical Center.

"It's something that's raising new questions about how to do reconstructive surgery on many of the survivors," Martin said.

Capt. Scott Quilty, a rifle platoon leader with the 10th Mountain Division, had been in Iraq for two months on Oct. 2, 2006, when he stepped on an improvised explosive device while on patrol near Baghdad. Surgeons amputated his right arm below the elbow and his right leg below the knee.

Now in rehab at Walter Reed, Quilty has a prosthetic hand that gives him the ability to hold a coffee cup and a prosthetic leg that helps him to walk. He spends about an hour a day exercising and makes a point of walking as much as he can. His plans include a stint in the Army Reserves and admission to law school.

The soft-spoken New Hampshire native is left-handed. But some daily tasks - like tying shoe laces or zipping up a jacket - have become more challenging. "It takes twice as much time to do some of those things as it used to," he said.

Quilty has had 15 surgical procedures to implant skin grafts and make other improvements - and his prosthesis still needs periodic adjustment because bones near the sites of the amputations continue to grow, a common problem for amputees.

"It's a long rehabilitation. Sometimes I feel like it's one step forward and two steps back," he said.

At the surgeons' conference this week, Quilty chatted briefly with Scott Rigsby, a double amputee and competitive athlete who considers himself lucky to be alive.

Rigsby, 39, was thrown from a pickup truck near his home in Georgia in 1986. Doctors amputated his right leg below the knee shortly after the accident. They removed his left leg in 1998, partly because of constant tissue breakdown and the risk of infection - and partly because he would be able to move more freely on two artificial legs.

Rigsby has had 17 surgeries, but he remains optimistic and energetic. He works out every day and has started two foundations to help physically challenged people pursue athletics. On Oct. 13, he became the first double below-the-knee amputee to complete the Ford Ironman Triathlon in Hawaii.

That's a 2.4-mile swim, a 112-mile bicycle race and a 26.2-mile marathon. He did it in 16 hours and 42 minutes. His goal: run another Ironman and beat that time.

For the race, Rigsby wore prosthetic legs with tiny flashlights attached because it got dark during the marathon. To move forward with confidence, he needed to see the road in front of him clearly.

"I can't feel my feet - so at least I have to be able to see them," he said.

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