“Face of Hope” (Published online as “New Hope for Soldiers Disfigured in War”)
by Liza Gross
Discover, September 2014
I specialize in taking deep dives into topics that haven’t been well covered elsewhere, as I did in “Toxic Origins of Disease,” an in-depth look at the science behind bisphenol A’s suspected health effects before the chemical became a household word. I also like to tackle a familiar problem from a new angle, as I did in “Broken Trust: Lessons from the Vaccine-Autism Wars,” which explores the persistence of vaccine doubts through a medical anthropologist’s lens. I wrote both stories while on staff at PLOS Biology. More recently, as a contributor to Environmental Health News, my story “No beba el agua,” which documents the disproportionate risks poor farmworkers in California’s Central Valley face from agricultural pollution, is due to receive honorable mention from the Oakes Award for Distinguished Environmental Journalism as part of the Pollution, Poverty, People of Color series.
For Discover, I propose a compelling human interest story that explores the groundbreaking science in tissue engineering and reconstructive surgery through the eyes of injured soldiers. It’s a tale about the strange symbiosis between the traumas of war and medical innovation, a phenomenon medical historians call “progress through bloodshed.”
Every war deploys new military technologies that inflict devastating injuries never seen before. The latest advances in protective gear often protect every part of a soldier’s body except the face—which enemy forces, some military experts think, now target. Battlefield surgeons invent new techniques on the fly to help soldiers survive dire wounds that would have killed them a generation ago. Back home, multidisciplinary teams of researchers and surgeons push the boundaries of science and medicine in an effort to piece together broken bodies and mangled faces. Often, the breakthroughs born of sacrifices in battle benefit us all.
Progress through Bloodshed
To hear Master Sergeant Todd Nelson tell the story, it was a day like any other in Afghanistan. He’d run more than 300 logistics convoys from Camp Eggers to the outskirts of Kabul and knew the drill: layer on the protective gear, keep your carbines fully loaded, and go heavy on the gas down Jalalabad Road to give your unarmored Land Cruiser a fighting chance to make it back to town in one piece. Armored vehicles are in short supply in Afghanistan, and logistics convoys often go without.
By chance, Nelson’s partner, Chris Sanders, wanted to drive that day. On the way back to base, about 7 miles from “home,” a small car and truck cut in front of them. Sanders veered left to pass. As he pulled even with the car, the driver looked Sanders in the eye, then tripped an improvised explosive device, blowing his car, and himself, to smithereens.
The force of high-energy shock waves from the blast crushed the bones in Nelson’s face. Accelerating bits of jagged metal and glass tore through his right eye and sinus cavity, obliterating his jawbones and forehead. Then came the fireball. Flames hotter than molten lava burned the flesh on his right side, from his leg to the top of his head, liquefying his nose, eyelids, and right ear.
Over the next three years, Nelson endured 43 surgeries, as an elite interdisciplinary team of military specialists tried to rebuild the features of his face, bit by painstaking bit.
“My nose is actually from my forehead,” says Nelson. “My cheeks are actually from my shoulders. The top of my head is from other body parts that we won’t mention in public.”
Only his cheeks benefited from the more functional and aesthetically appealing “full thickness” grafts, fashioned from full layers of both epidermis and the underlying dermis. For the grafts to take, Nelson says, “we literally had to cut my shoulders off and sew them to my cheeks and leave them attached to my shoulders for a month.” He tried to “go on living” during that time as best he could.
Facial trauma expert Colonel Robert Hale first saw Nelson in the burn unit at the Brooke Army Medical Center in San Antonio less than a week after the attack. “I honestly didn’t think he’d survive his injuries,” Hale says.
Hale, director of the craniomaxillofacial unit at the U.S. Army’s Institute of Surgical Research, retired from a lucrative practice as a plastic surgeon in Los Angeles to bring the best and brightest minds to the problem of rebuilding the faces and lives of Nelson and thousands like him who returned from Afghanistan with this new breed of catastrophic injury.
When Hale first started treating these soldiers, protocols to treat burns and reengineer skin and soft tissues hadn’t changed much since WWII. Treatments stop infection and cover the wound bed with skin harvested from unscathed body parts. But the treatments leave disfiguring scars, eyelids that don’t shut, noses that can’t inhale, mouths that can’t move.
The sheer scale—and devastation—of these wounds has led to a new round of innovation, spearheaded by top specialists at Brooke Army Medical Center at Fort Sam Houston in San Antonio, the military’s cutting-edge prosthetic clinic and its only advanced burn unit, and UCLA Medical Center’s Operation Mend, which launched the West’s first face transplant program last year. It also launched a clinical trial to demonstrate sensory-motor function and success of immunosuppression protocols in face transplant recipients.
But this “progress” comes at a cost, as the victims wrestle with wounds that strip away the features that define their very identity. Researchers are finding new ways to attend to the physical trauma visited on these horribly disfigured soldiers, with advances in facial reconstruction and now even face transplants. But progress on treating the psychological trauma lags behind. Soldiers with head injuries face a 50% greater risk of suicide.
The story I tell will be alternately heartbreaking—as I visit Nelson and soldiers like him, first at the Brooke Army Medical Center and then at the UCLA Medical Center—and hopeful, as I visit Hale and researchers at UCLA to explore the latest developments in the rapidly evolving fields of wound healing and full facial reconstructive surgery. The narrative will follow a soldier’s long path from injury to recovery while interweaving a bit of history of war-born innovations with the latest discoveries in wound healing mechanisms, tissue engineering, and regenerative medicine.
Afghanistan has already helped revolutionize wound care, Hale says. Advances are happening on multiple fronts, from the lab to the clinic. Newly identified blood-clotting agents that initiate wound repair but lead to heavy scarring have been coopted as “designer blood clots” that stabilize wounds on the battlefield and facilitate tissue repair while minimizing scarring.
The recently developed “wound vac” accelerates wound healing and skin graft adherence through a vacuum-assisted closure device that suctions off fluids around a piece of foam embedded in the depths of a wound. The device extends the time between a dressing change, a painful procedure for the severely injured. Over the past three years, researchers have adapted the technology to facial wounds, using a “biomask” to speed healing and replace the skin sequentially.
Experimental surgery techniques use stem-cell enriched fat to restore the skin and soft tissue that supports it. Injecting fat into reconstructed tissue adds volume and contour, but fat dissolves without its native blood supply. Kacey Marra, associate professor of plastic surgery and bioengineering and director of the Adipose Stem Cell Center at the University of Pittsburgh, hopes to circumvent this problem by using stem-cell enriched fat to stimulate blood vessel growth and combat fat wasting in facial reconstruction. She tests her techniques in mice, then moves on to a pig model before testing in humans. Investigators led by Dr. Peter Rubin, Marra’s colleague at the University of Pittsburgh, are running two clinical trials to evaluate the effectiveness and longevity of fat grafts, using a patient’s fat, to treat traumatic facial injury. They expect to post results by June of next year.
Stephen Feinberg, professor of surgery and dentistry at the University of Michigan in Ann Arbor, is directing Phase I and Phase II clinical trials to evaluate regenerative medicine and tissue bioengineering techniques to use composite skin grafts, engineered from tissues outside the body, to build more realistic, functional facial features.
Hale is hopeful that soldiers, and civilians, will see benefits from these advances soon. “All the technologies I’m exploiting currently in my research lab and funding in other research labs are things that are close at hand. In five, six, seven years, we should have products that we can apply and strategies we can apply to soldiers and marines injured in war. And it’s translatable to the general public.”
Aside from the fascinating nature of the science and how quickly it’s advancing, I believe this is an important story on many levels: nearly 40% of injured soldiers come back with traumatic facial injuries, but most Americans never see the human costs of these conflicts. When soldiers lose the features that define who they are, the scars penetrate far beneath the skin. In the modern era of warfare, soldiers also see civilians, even young children, blown to bits. We can marvel at the scientific advances triggered by military necessity. But we must ask if it’s progress.
I hope you’ll during well! Please let me know if you have any questions. I look forward to hearing from you soon!