Doctor Discusses Complexity of Rebuilding Faces of Injured Soldiers
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SUSAN DENTZER: Let’s start off by talking about Jeffrey. When you first saw him, what did he look like?
DR. JOE ROSEN: In late 2005 I was asked to look at him and provide suggestions. I was working with a team of plastic surgeons at Walter Reed that included Dr. Roy Harshbarger and Dr. Andy Friedman, as an outside consultant.
Jeffrey is somebody who fits a classical pattern, where he lost his mid-face and all the associated structures, so he has injuries to the lower jaw, upper jaw and nose. He also had additional injuries to his eyes.
We have to think about how to reconstruct it. So we think about what are all the things that are missing, what are all the things that are available to us around the body that we can borrow and move there, and what’s the approach?
He already had an injury to his right arm, so we looked at his left arm where you can take the forearm skin, part of the underlying bone. If you want you can take nerves with it, and you can take skin and bone, and then you can take this and transpose it up to the face. In this case we hooked it into arteries in his neck, so we find the artery and vein in the arm. There’s two of them that go to the hand, so you can steal one, which is a radial artery. You can test first to make sure that the hand can survive without the artery. And you bring it up and you attach it using microsurgery, very tiny needles and sutures, small enough that you can pass the needle through a hair on your head.
We bring this flap up and hook it into the neck and put it into the face and hook the bone from cheek to cheek with the soft tissue. We brought up extra soft tissue so some of that can end up being the lining for the eventual nose that we’re going to bring down. And we let that all heal.
So we did that back in March. It was about an 8 to 10 hour operation with two teams working, Dr. Friedman with someone else was working on the forearm, and Dr. Roy Harshbarger and myself were working on the face. The flap was then brought up from the arm to the face. We attached it, reestablished the blood supply. And again, it’s difficult because there’s a lot of injury to the face so you’re working through a scar. So once we have that established that provided our foundation for the later surgeries.
SUSAN DENTZER: Now let’s pull out some of the photos of the, of Jeffrey as he after he was brought back from Baghdad. A lot of preliminary work has been done just to stitch him back up, but this was before you got going.
DR. ROSEN: We had a photograph of his face and what we do is we sketch on the photograph where we think the tissue was before. We kind of zoom in on it, we start thinking about the lower lip, the upper lip, the nose, which are what we call cosmetic units, the segments you see as you look at a face. I think about the lower chin as one unit, the upper chin and lip as one unit, the nose as a unit. And I want to replace them as a solid unit so that when people see him afterwards it makes sense in terms of how the face it put together. And we work on all that and try to figure out how all that fits together.
We create models. We have a computer generated model from the CT scan we did of the head. So we have the data set, the real digital data. We can generate an image of the part that’s missing. A lot of emails go back and forth with suggestions back and forth as we as a consensus try to decide what’s best, what do we need to do to get him back to as close as possible to the original Jeffrey.
Difficulty in re-building the face
SUSAN DENTZER: Let's talk for a moment about the face as an organ system. Why is it hard to rebuild a face?
DR. ROSEN: The face does a number of things. There's form and function. The eyes see, the mouth allows you to eat and chew things. Your breathing comes through your nose and your mouth. There's also a key function of the face in terms of emotion. When I communicate with you the words are about a third of it, facial emotions about a third of it, the voice tone is about a third of it. So the face makes a third of how you express yourself to other people which is very important.
Â So when we look at all that, a lot of that's damaged by these types of injuries. We look at the nose, for instance. The nose is important in terms of the airway and breathing. When your air comes in, it moistens your air. But some people would argue the nose is more an appearance issue. Many more people have their nose changed and alter their appearance of their nose, than some of the other structures in your face. So when Jeffrey can't breathe through his nose, there's a big functional problem for him, he can only breathe through his mouth. That's why it's important for us to establish an airway, at least on one side and see how much that nose and that portion can still function for him. But it's also important to recreate his nose for his appearance.
SUSAN DENTZER: From your perspective as a plastic surgeon, what does a face mean to people, and what would be the emotional cost to a person of losing his face?
DR. ROSEN: In terms of our society and the way we deal with people, probably 90% of how we identify somebody is by the face. People identify you by your features in your face. And it's amazing how good we are at identifying somebody by their face. And it's amazing how important it is. The face is 80, 90% I think, of what we take into account when we consider ourselves to look human.
SUSAN DENTZER: In terms of its composition, as a mass of nerves and muscles, the face is a unique structure, isn't it?
DR. ROSEN: In the rest of the body, for instance, you sensor nerves that give you feeling and motor nerves that allow you to do things. In the face, you have these as well as still other nerves that interact with muscles in unique ways. When a fly lands on the back of a horse, the horse can shake its back because it has a special layer of muscles called the perniculus carnosum. And the only place on the body that humans have that is the face. So we have this special layer of muscles in the face which are the muscles that allow us to show emotion through impulses that are supplied by the facial nerves. That allows you to do those little funny things that make Susan, Susan as she moves her cheek in a certain way and move her forehead. Then there are deeper muscles, the usual skeletal muscles allow you to chew and do those things. Those are the kind of muscles we have everywhere else in the body.
In an injury like an explosion to the face, those muscles are shattered, so the question is, how best can we try to put them back together again. Part of it is injury directly to the nerves and part of it is the muscles themselves, the muscles units, and the nerves that go to those muscles. They're no longer there or they're scarred. We try to save whatever we can and put those in place. Earlier I talked about tissue engineering. The question is, can we tissue engineer new muscles to move in the face?
SUSAN DENTZER: So this interplay of these muscles, these nerves, those things can't be restored to Jeffrey, correct?
DR. ROSEN: The problem with the face is everything's details in the face. You can do all kinds of things with the face because of tiny little muscles. But we can't replace all those little muscles. And those muscles are shattered and my little muscles in my nose, those are gone. So all these little muscles really are at the limit of the technology and tools we have as plastic surgeons. Clinically we're doing as best we can, but with a lot of research, we could do more.
And I think the good news is that the Defense Department is stepping up to the plate and trying to address these issues. We can bring all these communities together -- robotics labs, tissue engineering labs -- to meet this challenge if the money is earmarked in an appropriate way. We have a lot of other issues right now that Congress and other people face in terms of high priority, but it's hard to imagine what's more high priority than a soldier who's sacrificed for the war, come back missing a limb, has a brain injury, is missing their face, not to try to do everything possible.
The country needs to focus around this. We have the need with these patients and we need to sort of start looking at how do we make this happen, not 10 years from now or 20 years from now, but what can we do tomorrow. They certainly sacrificed for the country for freedom, for all the things we believe in, why shouldn't we do as much as possible? They're already doing a lot, but the issue is what more can we do, and the answer is a lot.
Funding the project
SUSAN DENTZER: DARPA, the Defense Advance Research Projects Agency, hasn't decided yet whether to fund a "Virtual Face" project. Should it?
.DR. ROSEN: A small amount of support from DARPA for "Virtual Face" will suddenly garner a huge amount of support from other communities, robotics, as we talked about, or bioengineering, regeneration and in computer simulation and virtual reality. All those communities will step to the plate if DARPA takes the lead. Even if it's a small lead, it's just amazing once DARPA puts their kind of label on that this is a DARPA reality. And DARPA again really wants to take on a hard problem. I would argue the faces we can see today are really a hard problem. Certainly it's comparable in hardness to making a state-of-the-art robotic human arm, which is another DARPA project. So if we have an arm project, why not have a face project as well?
SUSAN DENTZER: Let's close by talking about what the best case scenario is for Jeffrey. Tell me, two or three years down the road, what he looks like as a human being.
DR. ROSEN: Injuries like Jeffrey's, where he lost so many of his parts, I don't think I'll ever get to the point where I'm looking at him and I don't know that I've done surgery on him. But I want to get him to the point where someone on the street won't stop and stare at him. I'll get to the point where he gets up and knows that he looks pretty reasonable. And society has to accommodate to the fact that he sacrificed for us, and we should be easy on him.
One of the greatest experiences in plastic surgery in this country was at Valley Forge in the 1940s, in 1800-vet hospital during World War II. A lot of the greats in plastic surgery, including a famous fellow named Joe Murray, got a start there. And in that environment they came up with a rule. And the rule was that the patient would eventually come to the doctor and say, "I've had enough surgery. I'm happy with where I am, or I can't do anymore." So the patient would come to a resolution.
SUSAN DENTZER: So you're saying in a way Jeffrey will be done when he decides he's done.
DR. ROSEN: Yes, and the nice thing about the military is that it is amazingly good at providing the resources we need to do what we want to do. So I will never run into the situation where they will say no, you need to stop. I can't say that for the other parts of our 21st century healthcare system, but I can certainly say it for the military component of it, whether or not it's Walter Reed or the VA system. They'll make what we need available, whether it's nurses, operating rooms, supplies, support, transportation.
Â So it's going to be up to Jeffrey to say no. He'll come to a certain point before I will, when he'll say, "Dr. Rosen, I appreciate what you've done, I think we've come a long way. I think I've had enough in terms of the amount of surgery I want. I just want to return to my life." And that'll be the way we'll part.