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New Treatments for Combat Facial Trauma

Great strides in techniques and technologies for injured warfighters

Military medical records from more than a decade of combat in Iraq and Afghanistan show about 30 percent of all wounded warriors suffered some form of facial injury, primarily resulting from the blast and high-energy ballistics of improvised explosive devices.

Those injuries include severe burns, fractures of the eye sockets, jaws and cheekbones, damage to or loss of eyes, ears, lips, teeth – often in combination and sometimes resulting in catastrophic damage to the face and underlying structures.

“Blast injuries cause holes in the face, expose parts of the face, and cause skin burns, in some cases down to the bone. So we have to come up with strategies on how to mitigate the effects of open wounds on the face, which are contaminated on the battlefield,” Col. Robert G. Hale, commander of the Army Dental and Trauma Research Detachment, told Defense Media Network.

Military and civilian medical personnel – from dentists to reconstructive surgeons – have worked throughout the years since 9/11 to not only save the lives of those suffering combat facial trauma, but to rebuild/replace the damaged areas in ways never before considered possible. The breakthrough techniques involved range from using 3-D printers to make replacement structures or scaffolds identical in size and shape to the originals, to performing full-face transplants.

University of Maryland Face Transplant Team

The team of University of Maryland doctors who performed the most successful full-face transplants. From left to right: Amir Dorafshar, MD, Michael Christy, MD, Eduardo Rodriguez, MD, DDS, Branko Bojovic, MD, Daniel Borsuk, MD. University of Maryland photo

A team of craniofacial and microsurgery specialists from the University of Maryland put their research program into practice in 2012 to perform one of the most extensive – and successful – full-face transplants ever attempted.

“The ultimate goal of this project was to treat the wounded warrior,” according to Dr. Eduardo D. Rodriguez, the team leader. “We wanted to develop a strategy that would essentially reconstruct the massive disfigurement of the face of these soldiers. The ultimate goal is not only to make these patients and soldiers appear well, but to also ensure that they function normally.

“As injuries between the lower face and upper face are considered very difficult injuries to treat, the operation to repair these injuries must be proportionate to the problem in order to take these patients to the next level. This would not have been possible with conventional measures.”

Before the patient entered the operating room for what would be a 36-hour surgery, Rodriguez said his team spent hundreds of hours in training and rehearsal, using computer simulations to study every aspect of the patient’s original facial structure and ensure precise oral/dental/tongue alignment so the patient would be able to chew and speak correctly.

“Blast injuries cause holes in the face, expose parts of the face, and cause skin burns, in some cases down to the bone. So we have to come up with strategies on how to mitigate the effects of open wounds on the face, which are contaminated on the battlefield,” Col. Robert G. Hale, commander of the Army Dental and Trauma Research Detachment, told Defense Media Network.

“Within hours, a bacteria film forms. We’ve known about this for centuries, but only in recent years have we been able to characterize and study, in lab conditions, the actual bacteria and how to use that biofilm and reduce its effects, which are delayed wound closure, scars, and deformities.”

Treatment begins with wound healing, without which, Hale said, further treatment would be impossible. After that, the options include reconstructive surgery, which has been performed and evolving for more than a century; restoration, where damaged areas are replaced rather than repaired (face transplants being the most extreme example); and regeneration, where replacement skin, bones, teeth, etc., are “grown” in the lab, using the patient’s own cells.

Combat Facial Trauma

Petty Officer 3rd Class Bradley Erickson, hospital corpsman, assigned to 1st Platoon, India Company, 3rd Battalion, 6th Marine Regiment, Regimental Combat Team 7, cleans facial wounds for Lance Cpl. Timothy Mixon after an improvised explosive device attack during a patrol, May 1, 2010. The rise in combat facial injuries after more than a decade of war has led to innovative medical technologies. U.S. Marine Corps photo by Cpl. Michael J. Ayotte

“Biofilm repair wound healing may not look like dentistry, but it is, because dentistry goes beyond the tooth to involve the entire facial structure,” he added. “We team up with orthopedic researchers to share expertise and information [on] tissue injury research. Their scaffolds, biocells, and stem cell research ally very well with ours.”

Eye injuries also are a major element of this war, with an estimated 16 percent of all wounded warfighters suffering eye trauma. That, too, is requiring new levels of treatment and new directions for future development.

“There are no civilian injuries that come close to what we are facing on today’s battlefield from blast injuries. It’s not unusual for doctors at Walter Reed [National Military Medical Center] and Landstuhl [Regional Medical Center, Germany] to spend hours trying to rebuild an eyeball that was severely damaged,” according to Dr. Tom Zampieri, a former Army medic and flight surgeon now serving as director of government relations for the Blinded Veterans Association.

“An Air Force surgeon on his third combat deployment recently told me the magnitude of facial injuries from this war is unbelievable. In the past, people with such horrific injuries never would have made it off the battlefield alive. Today, they do and we have to figure out how to put a private’s face back together and often restore vision.”

Despite the high incidence of facial trauma from combat in Southwest Asia – the VA reports some 100,000 new veterans with eye injuries have entered their system since October 2001 – officials say only 3.5 percent of facial wounds have resulted in death, compared to more than 40 percent during World War II.

“The dental maxillofacial area is really focused on developing a higher quality skin regenerate, which is what we do with scaffolds and stem cells, because we have that higher requirement,” Hale concluded. “If there is a really badly scarred face, there isn’t much that can be done other than a face transplant, which is a consideration. But if in the next few years we can regenerate the face, that would be better.”

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J.R. Wilson has been a full-time freelance writer, focusing primarily on aerospace, defense and high...